Government-Run Healthcare “Despite” Obama?
November 6th, 2008 by DrRich
In his campaign, President-elect Obama did not promise or even advocate a universal healthcare system controlled by the government. Indeed, he referred to government-run healthcare as an “extreme” option that ought to be avoided. Instead, he advocated a system in which people who liked their current health insurance would be permitted to keep it, while those who did not have health insurance or who did not like their current insurance would be able to join a new government insurance plan, based on the plan “available to members of Congress.”
Conservatives and cynics, of course, pointed out that such a plan amounted only to a stealth government takeover of healthcare. Since the new government insurance plan would be competing with private insurance, and since the government would be establishing the rules of competition, it would be a simple matter to arrange things so that, before too long, the private competition would melt away.
As a matter of fact, DrRich himself painted such a scenario, and even suggested that the insurance company executives were supporting Obama over McCain during the election precisely because Obama would present them with a graceful (and lucrative) exit strategy. (Mr. McCain’s plan, in contrast, relied on insurance companies to invent the “efficiencies” that would control healthcare costs, as if the insurance companies hadn’t already been trying unsuccessfully to control those costs for 20 years, and were not already completely bereft of useful ideas.)
The fervent wish of the insurance executives, DrRich surmised, was this: Mr. Obama would provide them with one last, huge windfall, in the form of government-provided premiums for some significant chunk of the 47 million uninsured Americans. Then (DrRich went on) a couple of years later and having realized their final gains, they would get out of the health insurance business altogether and let the feds have the whole mess.
But now, things have changed.
Thanks to the sub-prime mortgage crisis and the economic meltdown that has resulted, it will be difficult if not impossible for Mr. Obama to implement any sort of organized healthcare reform, or any other reform that promises to greatly increase federal spending. (Dick Morris points out in a column today that the realities of our current economic situation will serve as a general constraint to the Democrats now controlling the administration and both houses of Congress.)
But if Obama-style healthcare reform is off the table, or even significantly delayed, the health insurance companies are likely to be in deep trouble - and soon.
The market value (i.e., stock price) of these companies completely relies on their continued growth. Through the 1990s and for the first half of this decade, their growth was spurred by the acquisition of public assets (not-for-profit institutions) at a tiny fraction of their real value, and on mergers and acquisitions among insurers. But there are no more non-profits to take over, and these companies have pretty much run out the string on mergers. So, for the past few years their growth has almost solely relied on their participation in government programs such as the Medicare Advantage Plans (which, by the way, may be going away soon given the recent election results). The entire prospect for future growth (and therefore viability) in the health insurance industry, as DrRich has explained, depends on an Obama-style expansion of government programs that will provide a new stream of insurance premiums.
One sure thing is that health insurance companies have no hope of even maintaining their current profitability, let alone continuing their growth, solely by doing what they are supposed to be doing - by managing the healthcare of their enrollees. (The prospect of having to survive by doing that, once again, is what frightened them so much about the McCain plan.)
Panicked insurance company executives are not in a pretty place. On top of a mounting recession in which their customers (American businesses) are cutting back or failing, and during which their own costs continue to increase at a double-digit rate of inflation, they now have to face the likelihood that in spite of Mr. Obama’s election there won’t be a massive infusion of government dollars into their businesses any time soon. These poor souls are very likely casting about for a Plan B.
And Plan B seems pretty obvious to DrRich. The path has been very recently blazed by others.
Over the last two months it has become obvious that when businesses vital to the public welfare are about to fail, the government has little choice but to take them over. This was the case with AIG, with Fanny and Freddy, and to a lesser extent with several major banks. We now see the American auto industry lining up for a bailout/takeover. It is easy to imagine the gasping airline companies forming themselves up into the same landing pattern.
So if you are a health insurance executive, you are probably looking at your current broken business model, lamenting that your savior Mr. Obama is probably not going to be able to come to your rescue with the one last windfall he has promised, and observing what is happening with other “vital” American industries in similar straits. DrRich imagines that these executives have already resolved themselves to a government takeover (indeed, this was the end-game they have long planned once their last Obama windfall played itself out), and that they are merely calculating the right moment for it. How best to divest their stock before hinting that such a takeover is in the works? With careful planning and negotiation, can some of the takeover money be parlayed into executive bonuses, or at least into one last, extravagant junket (a la AIG)? There is no real hurry, after all - whenever the health insurance industry says it just can’t do this any more and that the government needs to take over healthcare, then no matter which other industries the government will have already acquired, what choice will the feds have?
If DrRich is right in such speculations, we may end up with government-run healthcare sooner than we think, despite the promises and intentions of Mr. Obama, and despite the seeming unlikelihood of achieving organized healthcare reform in the foreseeable future.
DrRich humbly suggests that those who currently own stock in health insurance companies should take note of what happened to the shareholders of AIG and other companies whose demise the feds have recently engineered - which is to say, they were completely wiped out. DrRich is not really trying to give investment advice here, and admits to being entirely unqualified to do so, as anyone would agree who saw his portfolio. He’s just sayin’.
The Real Reason Americans Have a Right to Healthcare
October 30th, 2008 by DrRich
In recent posts (here, here and here), DrRich has considered the legitimacy and the implications of our recently-announced right to healthcare.
In one of those “meditations” DrRich decided that declaring healthcare to be a right is indeed legitimate, but not because it is the only humane thing to do, or because there is some sort of a natural right to healthcare, but rather, due to the BOSS rule (that is, Because Obama Says So), which is simply another manifestation of the longstanding principle that the sovereign authority gets to declare anything he/she/it wishes to be a right.
At this time, DrRich wishes to drop his usual sarcasm, to the furthest extent possible, and explain why Americans in truth have a legitimate claim to a right to healthcare - even if the electorate (through some unaccountable fluke) should fail to consummate their promised elevation of Mr. Obama, thus, incredibly, negating the BOSS rule.
In short, Americans have a right to healthcare because they’re paying for it.
Under our present system, every person living in the United States is sharing in the cost of healthcare for every person who receives healthcare. Let us list some of the ways in which this is true:
1) Anyone receiving a paycheck is subject to payroll deductions to pay for Medicare for the elderly and Medicaid for the poor.
2) Anyone paying income tax is paying higher tax rates to offset tax-deductible health insurance premiums purchased by businesses for their employees. (That is, employer-provided health insurance is subsidized by the taxpayer.)
3) Anyone buying products in the U.S. is paying higher prices to cover the healthcare costs of American businesses.
4) Anyone living in America is sharing in the massive societal burden we are creating by allowing healthcare spending to be passed off to future generations, by way of the national debt.
These costs, and more, are borne by everybody living in the U.S. Since everyone in one or more ways is paying for healthcare, everyone has a just claim - a right - to some of that healthcare.
It is important to notice that this argument for a right to healthcare is fundamentally different from the arguments typically given. Typically, a right to healthcare takes on the characteristics of an entitlement, a grant bestowed on individuals by society just because of who they are (such as, citizens, people over 65 years of age, etc.) A right like this - an entitlement - is rarely taken away, or even limited, once granted. Entitlements are soon seen by their recipients (and by the bureaucracy that administers and regulates them) as something that is owed forever, as a natural, God-given right, which can always be expanded, but never ever restricted.
In contrast, the right to healthcare which DrRich is describing is not “granted” to an individual by a beneficent society because of some inherent characteristic of the recipient, but rather, comes into being solely as a result of their being party to a social contract, under which healthcare is a consideration given in return for certain obligations the individual makes to society. Those obligations would include paying for the publicly-funded healthcare through taxes, and subjecting oneself to whatever limits to publicly-funded healthcare such a system requires in order to maintain societal integrity.
This kind of contractual right to healthcare would enable us to set necessary limits on what we mean by healthcare. There would no longer be an obligation to provide individuals with every manner of available healthcare under all circumstances, but only to provide individuals with that level of healthcare provided as a public benefit to all other individuals, under the terms of the social contract. (An entitlement, in contrast, generally is an open-ended promise in which “healthcare” comprises anything and everything one might think has any possibility of restoring every bit of health.)
To summarize, as DrRich sees it we have already created an obligation to provide publicly-funded healthcare to all individuals, by virtue of the fact that we have already burdened every individual with the cost of healthcare for anyone who is now receiving it. We might as well own up to our responsibilities with a formal contract that recognizes the widely-shared cost of American healthcare, that recognizes the right of all Americans to the considerations that arise from this widely-shared burden, and that establishes clear limits to the obligations borne by the parties, limits that are part of any legitimate contract.
Such a social contract will finally give us the framework we need for a public discussion on setting necessary limits on publicly-subsidized healthcare spending.
Why Conservatives Shouldn’t Sweat Our New Right to Healthcare
October 27th, 2008 by DrRich
In response to a couple of recent posts (here and here) defending the declaration by President-Nearly-Elect Obama that healthcare is a right, several readers have offered comments indicating that simply declaring healthcare to be a right is not very useful, unless you also clearly say what you mean by “healthcare.”
This is indeed the question. Exactly how much healthcare are you entitled to if you have a right to healthcare? Do you have a right to certain specified healthcare services, to a certain dollar amount of healthcare per year or per lifetime, to whatever healthcare it takes to achieve perfect health, or to some other limit or non-limit?
The question of limits (whether we should have them or not, and what should they be) has been a central theme of this blog and of DrRich’s book. To reiterate the fundamental problem: 1) In America we believe that it is wrong to limit healthcare in any way, that everyone is entitled to the very best healthcare, that any bit of healthcare that offers even a small potential of benefit should be provided, and that death itself is merely a manifestation of insufficient research (or actionable incompetence, or systematic discrimination against the unwealthy, or corporate greed). 2) But against that closely held belief, we must balance the unremitting law of economics which tells us that there is simply not enough money in the known universe to buy all the healthcare that might potentially offer some small amount of benefit to every person. Healthcare spending has to be limited, or it will become a fiscal black hole.*
Our insistence upon simultaneously balancing these two utterly incompatible factors (the rock-solid belief that there are and can be no limits vs. the unalterable law that limits are unavoidable) requires us to do the necessary rationing of our healthcare (that is, withholding at least some potentially useful healthcare from at least some of the people who might benefit from it) covertly.
So, our entire healthcare system, from all three branches of the government, to health insurance companies, to hospitals, to doctors, to individual Americans (at least when they themselves are not actively patients), are fully and extravagantly and enthusiastically engaged in covert rationing, by a thousand different mechanisms, some of which have been chronicled here.
One reason DrRich is not as reluctant as some to accede to the notion that healthcare is a right is that such a declaration might, at last, move us closer to the day when we will actually be forced to engage in a public discussion of what we mean by healthcare; that is, will move us closer to deciding what should be the limits of healthcare.
Consider: When we have tens of millions of uninsured Americans who don’t have ready access to regular and routine healthcare, then it’s relatively easy to pretend that “healthcare” should include everything we might want it to include. By using the uninsured as a huge fiscal safety valve for our dysfunctional healthcare system - a valve that can be opened, as needed, to increase the number of people ineligible to consume routine healthcare - we can shore up the fiction that “healthcare” ought to have no limits. (Indeed, steadily increasing the number of uninsured Americans has become perhaps our most effective mechanism of covert rationing). This simple expediency alone goes a long way toward enabling us to avoid having to consider or discuss limits.
But once healthcare becomes a right, then presumably those (currently) 47 million Americans will suddenly have a claim to equal access to whatever it turns out we mean by healthcare. The severe fiscal stress produced by this sudden influx of entitled Americans will likely force us, finally, to explicitly define the limits of what we should expect from our healthcare system.
Defining those limits will be extraordinarily painful, and will very probably traumatize our social structure. However, the process is necessary, because if we fail to set those limits the resulting fiscal tsunami - which will utterly dwarf the economic trifle we’re dealing with today as a result of the mortgage crisis - will leave us without any social structure to traumatize.
If declaring healthcare to be a right causes us to engage in this painful exercise now, before it is too late, then DrRich is in favor of it. Even American conservatives ought to be thanking Mr. Obama for doing his bit to bring the issue to a head.
*In contrast, our national, de facto declared right to affordable mortgages for everyone, no matter one’s credit risk, will result in some finite, limited amount of national debt, since every home has some finite, limited value. Even if the final cost to society is very, very large, a national right to home ownership in fact results in a fiscal obligation for society that is limited and quantifiable, and in one way or another is therefore ultimately manageable.
Anyone who insists that there must also be similar inherent limits on what we can spend on healthcare should simply consider that once we have artificial hearts, artificial kidneys, artificial livers, and can indefinitely preserve brain function sufficient to, perhaps, plug aged-but-medically-preserved bodies into some sort of virtual reality where they can frolic like virtual children forever (DrRich does not really know what medical immortality will turn out to look like, just that it is the ultimate goal of medical research, as any real American can tell you), then the amount of money we can spend on any given individual’s healthcare becomes limitless. It is indeed nearly limitless with just the stuff we have today.
How to Sell Assisted Suicide
August 10th, 2008 by DrRich
In July, the Oregon Health Plan injudiciously sent a letter to lung-cancer patient Barbara Wagner denying coverage for the expensive chemotherapy her doctor had recommended, and offering instead to cover palliative care “including doctor-assisted suicide.”
The firestorm of outrage this letter triggered (to see the outrage for yourself, simply Google the search terms “Barbara Wagner” and “suicide”) penetrated even the dulled sensibilities of the Oregon insurance executives. One Jim Sellers, a spokesman for the Oregon Health Plan, admitted to ABC News that “the letter to Wagner was a public relations blunder and something the state is ‘working on.’”
DrRich expects that the Oregon Plan executives must feel at least a little blindsided by the general reaction to their ham-fisted denial letter. Denial letters, after all, routinely list (as an aid to the patient) services which the insurance company judges to be reasonable alternatives to the denied care. While in this case the denied service offered some reasonable hope for prolonged survival, and the service being offered as an alternative (to say the least) did not, that’s really not so much different from the content of more “routine” denial letters. The difference is one of degree, and not of substance. So, Oregon Plan executives might be thinking, “What’s the big deal?”
One must try to be understanding of such insensitivity. It is a fundamental task of health plans to deliver unpleasant news to people whose lives are at stake, and it is normal – even necessary – for those who are charged with this task to grow thick skin. It is perfectly predictable that such thick skin might dull one’s ability to discern subtle differences in degree between various denials of services, subtle differences that might call for more artful phraseologies than those employed in this instance by the Oregon Plan. The failure to recognize the need for a more artful denial letter, Mr. Sellers appears to say, is the problem in the case of Ms. Wagner. The solution, consequently, is not a substantive change in any policy, but better public relations.
Those who run the Oregon Health Plan must be particularly disheartened to learn that even vocal proponents of physician-assisted suicide are criticizing their ill-considered denial letter. To so blatantly juxtapose healthcare rationing with the “option” of assisted suicide seriously undermines the chief argument advanced publicly by the end-of-life movement, namely, that assisted suicide is primarily an individual autonomy play*, and not primarily a cost-saving mechanism.
In other words, whether or not you embrace physician-assisted suicide, everyone seems to agree that offering it as a covered medical service immediately after denying potentially life-prolonging therapy is both insensitive and unseemly.
And so – as a public service to insurance executives in both the government and the private sector who are severely challenged by trying to understand simple human emotions, to patients like Ms. Wagner who may suffer true physical harm by exposure to such institutional callousness, and to the rest of us who simply would appreciate not being confronted so blatantly by the dark abyss that underlies our healthcare system – DrRich offers some friendly advice to health plans on the right way to sell physician-assisted suicide.
How Health Plans Should Sell Assisted Suicide
1) Don’t be so anxious.
Sure it’s easy to get excited about physician-assisted suicide. All you need to do is look at your own data. Whatever sort of health plan you are running, it’s likely that a huge proportion of your spending goes to patients who are in the last year of life. Enticing these end-of-lifers to choose assisted suicide (which you can accomplish in a sufficiently tasteful way for about $100) is such an attractive proposition that it’s indeed become very hard to make yourself appear reasonably circumspect about it. At the very least, it’s difficult not to push the idea out there to your subscribers. Otherwise how can you be sure they know all their options for end-of-life care?
But doing even that much is a mistake. If you don’t believe that, simply look at the small firestorm the Oregon Health Plan created with their simple and helpful “reminder” letter to Ms. Wagner. As a result, neighboring states that appeared ready to pass their own assisted-suicide laws are now having second thoughts about it. It is clear that for a health plan to seem overly interested in assisted suicide, or even to mention the option to their subscribers, is a very counterproductive idea.
A much more subtle approach is required.
2) Publicly disown assisted suicide.
Think about Tom Sawyer whitewashing the picket fence. Ole Tom didn’t get all his friends to paint that fence for him by asking for their help, or by overtly trying to sell or cajole them on the idea. Instead, he got them to do the job by pretending he wasn’t the least bit interested in having them do it, by ignoring them altogether, and making himself seem completely absorbed in the delightful task. By the time Tom was done, his friends were begging for a turn, and even giving him wondrous gifts (such as dead cats on a string) to bribe him for a chance to participate.
What you need to do is pretend that encouraging assisted suicide – even if it’s a covered service that patients ought to be made aware of – is the farthest thing from your mind. Instead, you are completely invested in and insistent upon providing full-service end-of-life care, with all the bells and whistles and no holds barred; and – while patients of course have the option to exercise their individual autonomy as they see fit – you take great pride in squeezing every last instant of life out of those elderly, used-up, chronically ill bodies that present themselves in your ICU, no matter what the cost to the patient and family in terms of pain, suffering, humiliation and anguish. It is your mission to stave off death to the bitter end, come what may, and you’re proud of it.
3) Have somebody else push it.
In the meantime, clear the path for agencies and interest groups which are dedicated to the end-of-life movement. There are plenty of them out there. Have them do the selling for you.
Make sure they have access to your patients and patients’ families, especially in the ICU setting. Allow them space for educational displays; provide them some private space where they can talk to interested patients and families; see that hospital social workers are aware of their presence. In the meantime, make it clear you do not endorse or encourage their efforts, and indeed wish they would go away, but are providing such groups with access in the interest of full transparency and your dedication to patient choice. If patients choose to avail themselves of such information, you will do nothing to stop them.
4) Make the advantages to assisted suicide seem real.
There’s no need for you to talk up the advantages of assisted suicide – let the end-of-life proselytizers do the talking for you. All you have to do is to make their arguments seem accurate. The great part is, that’s just a matter of maintaining business as usual.
The end-of-life zealots will tell patients that assisted suicide is a way of asserting some measure of control over the dying process, of holding on to some level of personal dignity at the very end. So simply make sure your end-of-life care continues robbing patients of any semblance of dignity and control.
They’ll tell patients that assisted suicide will end pain and discomfort and suffering when all hope of recovery is gone. So simply continue with inadequate pain control** and half-hearted comfort measures, and keep the ICU as hectic, loud, scary and impersonal as possible.
They’ll tell patients that assisted suicide will finally bring comfort to their long-suffering family and friends. So make sure family and friends suffer long, by keeping those ICU waiting rooms hot, cramped, noisy, uncomfortable and smelly.
You get the idea. Simply make sure the arguments of the end-of-lifers have teeth. You’re good at that.
5) Tell patients to consult with their doctors before making this choice.
That’s right. Refer patients to their doctors, their supposed personal advocates, the selfsame individuals you yourself have long since fatally compromised (by grabbing control of their individual professional viability). Assuming you have placed sufficient cost-cutting pressures on your doctors, then their willingness to encourage (or at least not discourage) assisted suicide will increase substantially. So when patients do consult with their doctors, the doctors will not undermine your subtle efforts, but will be your partners in convincing those approaching end-of-life to just be reasonable.
6) Make physician-assisted suicide legal, but not reimbursable.
You’re going for the Botox model here. You do not want physician-assisted suicide to be merely another hush-hush medical procedure, conducted quietly and almost secretly in a typical doctor’s office, so that people can pretend it doesn’t exist. Rather, you want to establish it as something that’s front and center, something people will want and ask for and go out of their way to seek. You want to encourage doctors to establish inventive business models for assisted suicide, just as dermatologists have done for Botox clinics.
Accomplishing this, of course, will require assisted suicide to be made legal everywhere (and not just in Oregon and a few other progressive states), but at the same time will require you to NOT make it a reimbursable medical service.*** For once it’s made reimbursable it will become subject to typical healthcare price controls, and you will severely limit the possibilities.
Think of those possibilities: One envisions physician-assisted suicide becoming established as a “life cycle event” like a wedding or Bar Mitzvah, where the right atmosphere, the right spirituality, and the right tone come together to create an unforgettable, uplifting experience for everyone. Some assisted suicides will take place in a doctor’s office, of course, but why not in a place of worship, a favorite city, a resort, a mountain top, a rocky coast, a casino? Why not allow the prospective decedent to actually hear the eulogies and experience the tearful tributes before actually engaging (ritually) in the Act? Why not partner with the deathcare industry to wrap the final healthcare service into a comprehensive package with funeral services? Why not engage American media to celebrate the event with a new mode of reality programming (one that is sure to garner a massive share of viewers)? Why not convert what is today an antiseptic, impersonal and frightening process into one that makes everybody present say, “Yes! That’s the way to go!”
The beauty is that this sort of model will convert what is today, at best, merely the option for assisted suicide into something that’s expected – a true destination event, a natural part of life. Indeed, not opting for assisted suicide, at a certain point in one’s life, will come to be seen as being unreasonable, greedy and selfish. And when granny begins to spend more time in a doctor’s office or (worse) in a hospital where frequent visitation is expected (and other family inconveniences are generated), some loving grandchild will pat her precious wrinkled hand, and say, “Granny, you know, it’s getting to be about that time. Wouldn’t a last weekend in Vegas be just the thing?”
So, if you play your cards right - passively encouraging the end-of-life movement in its effort to spread the word, while making the alternative (i.e., not committing suicide) as nasty and foul an option as possible, and also while coercing doctors and encouraging families to view assisted suicide as the most advantageous modus exodus one could ever imagine – well, the “right” to assisted suicide will shortly become the expectation and even the duty for assisted suicide.
And if those who run health plans will just follow DrRich’s program, you will have accomplished all this without seeming crass and self-serving as you most certainly do each time you send somebody a letter like the one you sent the unfortunate Ms. Wagner.
*Preserving the ethical precept of individual autonomy is the basis upon which modern utilitarian ethicists build their defense of physician-assisted suicide, passive euthanasia, active euthanasia, and even involuntary, secret euthanasia. DrRich will elaborate on the ethicists’ defense of doctors killing people in a future posting.
**This will simply require the government to continue severely and very publicly prosecuting the occasional pain-management doctor. Whether the target physician is actually engaging in analgesic excesses is unimportant to the goal of making any American doctor afraid of aggressively controlling their patients’ pain, for fear of becoming a target themselves.
***You may need to fashion the payment model so that assisted suicide is paid for in the case of hospitalized patients, and for patients in Medicaid programs. The point is to make assisted suicide a highly-desired self-pay service for anybody with enough money for a decent car or central air conditioning.
More Guidelines - Fighting For the Children
August 4th, 2008 by DrRich
A few months ago, DrRich addressed certain disadvantages that will arise from a policy of forcing physicians to practice medicine by guidelines. Essentially, once we decide to measure physician quality and determine physician pay according to how well they “perform” in following handed-down clinical guidelines, we will open a Pandora’s Box of dysfunctional and contradictory guidelines that will make the IRS code - or even the Medicare policy manual - seem straightforward and logical.
Payers are placing much hope in guidelines. They envision great cost savings through the simple expediency of adopting guidelines that leave out certain medical services they would like to avoid paying for.
But the payers have made the grave strategic error of fully embracing the “guideline movement” before securing for themselves control of the guideline development process. Apparently they missed the obvious fact that, if the practice of medicine is is reduced to following sets of guidelines, then any healthcare group and any medical organization with any stature whatsoever will begin manufacturing guidelines that direct doctors to do whatever it is that advances that organization’s agenda. That is, if guidelines determine who gets paid for what, then guideline development will become the chief byproduct of the healthcare system. We are beginning to see this chaotic process in action now.
DrRich, who delights in attempting to tease order from chaos, has suggested several specific categories of the dysfunctional guidelines that will inevitably flow from such a process. One of these categories he labeled “predatory guidelines.”
As an example of predatory guidelines, DrRich pointed to the recent recommendations advanced by the American Heart Association (AHA) urging that children with ADHD be screened with ECGs before they are placed on stimulant medication. Those ECGs, the AHA went on to explain, should be interpreted not by the pediatrician, but instead by “a pediatric cardiologist or a cardiologist or a physician with expertise in reading pediatric electrocardiograms.”
In making this recommendation the cardiologists of the AHA have attempted to encroach upon the turf of the pediatricians, ostensibly to save the lives of innocent children, but in a manner that will inevitably increase business for cardiologists by a) generating hundreds of thousands of ECGs for them to interpret at $25 - $50 a pop, and b) generating tens of thousands of echocardiograms and other cardiac tests that will be necessary to evaluate all the equivocal (and to a very large extent false positive) ECGs that will result from this routine screening, while c) explicitly leaving the pediatricians themselves out of the process.
DrRich predicted at the time that the pediatricians would not allow this invasion of their turf to stand, and that they would find it necessary to counter with their own set of guidelines. And so, what began as “predatory guidelines” from cardiologists would likely degenerate into “dueling guidelines” between cardiologists and pediatricians.
DrRich is delighted to report that his prediction has now come to pass.
The American Academy of Pediatrics (AAP) has just released a policy statement suggesting that the AHA is guilty of promulgating bad advice. Indeed, the AAP finds, it is not necessary to perform routine ECGs on children with ADHD prior to giving them stimulant medication. Further, the AAP pointedly demonstrates that the AHA’s recommendations were based on faulty science (that is, the AHA failed to follow the principles of evidence-based medicine), and that those recommendations give at least the appearance of being self-serving. Finally, the AAP notes that since routine ECG screening produces many false positive results, which themselves require further cardiac testing, this screening actually produces more harm than good. So, the AAP concludes, not only is there no need to do routine ECG screening, but also doing the screening would produce net harm. The AAP statement stops just short of accusing the AHA of malfeasance.
And so, DrRich would like to thank the AAP for so clearly bearing out his prediction that “predatory guidelines” will always tend to yield “dueling guidelines.”
Needless to say, the cardiologists are not happy about this new development. Dr. Steven Nissen (famous of the Cleveland Clinic, and also famous for producing inflammatory statements pretty much on cue) tells TheHeart.org (professional registration required) that “the AAP statement is misguided.” Nissen also suggests, perhaps a bit gratuitously, that the pediatricians (and their friends, the detestable shrinks) are tossing amphetamines around like candy. He says, “This is the second time in a few weeks where the AAP has issued poorly thought out guidelines that promote inappropriate drug use in children. The previous statement promoted statin use in children as young as 8 years of age.”
(DrRich is sympathetic to the notion that the diagnosis of ADHD might be a tad overdone these days, to the point where being a boy is all but an official disease, for which drug therapy is frequently urged and often prescribed. But still, in the debate over whether children diagnosed with ADHD should have ECG screening before being drugged, the assertion that they are being overtreated in the first place is actually beside the point.)
Both sides in this now-very-public debate seem to have some valid points, and to DrRich’s estimation neither side is obviously completely right or completely wrong. Cardiologists are correct in pointing out that stimulant drugs do have cardiovascular effects, and it is logical to think that kids who are susceptible to cardiac arrhythmias might be at higher risk on these drugs, and that screening these kids might save some lives. But the pediatricians are correct in pointing out that the data that has been collected so far does not show any increase in sudden death in kids on drug therapy for ADHD when compared to the general population, that the same cardiovascular effects caused by these drugs are also caused by everyday activities such as running, jumping, and the sort of emotional outbursts that children with untreated ADHD may have from time to time, and that, besides, doing ECGs on all these kids has a known downside in terms of unnecessary procedures and increased cost.
So, in addition to being unseemly, these dueling guidelines create a dilemma (instead of guidance) for doctors who are actually attempting to care for children with ADHD. One set of guidelines says that screening is necessary to save lives; the other (from an equally regarded professional organization) says that not only is screening unnecessary, but also harmful. Whatever the doctor does, if there is a bad outcome the plaintiff’s attorney will come pre-armed with one set of guidelines or the other which will prove that, no matter what the doctor did, it was the wrong thing.
These dueling guidelines also demonstrate that many important medical questions are simply not suitable subjects for guidelines. Guidelines are fine when a medical issue is resolved, that is, when there is substantial agreement among experts (of all relevant factions) as to how patients with a certain medical condition ought to be managed. But guidelines are helpful only when the clinical question is sufficiently ripe. Premature guidelines - the ones promulgated for some other reason than that the optimal clinical pathway has been resolved - will cause harm (and often, ironically, will increase cost).
Nonetheless, the notion that the practice of medicine can be completely reduced to sets of guidelines (a notion vitally attractive to insurance companies and government bureaucrats), now has been broadcast with great fanfare across the land. It is through guidelines that we will finally homogenize healthcare, and establish the tools by which clinical excellence can be tabulated and costs can be controlled. So, as a consequence of this generally agreed-upon fiction, swarms of guidelines are now flying out of the medical establishment like bats out of a cave. We can expect many of these guidelines to be created not because clinical science warrants them, but instead to covertly ration care, to protect professional turf, or to aggressively extend one’s interests onto entirely new turf.
And so, spectacles like this one, where cardiologists and pediatricians have become engaged in a rather nasty turf battle (fighting for the children, as it were), will be repeated countless times across the medical landscape.
Cry havoc, and let loose the dogs of guidelines!
Skin in the Game
July 30th, 2008 by DrRich
The New York Times recently took dermatologists to task for creating a two-tiered system of dermatology - 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 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, old magazines, unruly children of other patients, and surly office personnel. Eventually her name is called by a not-necessarily-pleasant nurse practitioner who will “triage” her to the appropriate category (e.g., acne, fungus, cancer, warts- you know, dermatology stuff), have her strip in order to fully expose the large surface-area organ (the skin) for which she has sought assistance, give her a scratchy yellow paper gown to cover her nakedness, and have her wait for some time in a chilly exam room to see 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, shoving into the patient’s arms her bra and other structural and non-structural equipage, the doctor pushes her out into the hall, as the formal interview is over.
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 those who are about to appear in public, say, at an impending dinner party. 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 formal 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, agreeing, 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 solicitation 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 results.
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 commentators and reporters of the New York Times and any other concerned Americans 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. 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 widgets on an assembly line, then goes to her other, better office on Wednesday, treating the merely cosmetically-challenged like minor nobility, she is not really engaging in two-tiered healthcare. Not at all. Instead, she is practicing real, true, prescribed-by-society, by-the-book American healthcare on Tuesday, and doing Something Altogether Different on Wednesday.
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 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, folks would do just fine with it.
Of course, doctors in general (and dermatologists in particular) 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 results 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 offense.
And consider this. Dermatologists could just as easily have taken up a somewhat different well-known cosmetic procedure, one that also involves injecting substances through the skin via needles, and that has much more to do with the skin itself than Botox injections (which actually do not affect the skin itself at all, only the muscles under the skin), but they chose not to. DrRich speaks, of course, 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, of course, is that injecting Botox does not involve intrinsic skill, knowledge, difficulty, risk, or any other objective characteristic that necessarily renders this a medical procedure while ear-piercing and tattooing are not. Viewed from this perspective, one must conclude that declaring the injection of Botox to be a medical procedure, which cannot be performed by anyone not having a medical license and years of specialty training, is an entirely arbitrary determination.
Fundamentally, then, while performing Botox injections may have a certain legal status, in any true sense it is not really practicing medicine. Rather, it is simply an activity some dermatologists may choose to do when they’re not doing real dermatology.
Doctors engage in this sort of thing all the time. 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 go to graduate school (usually for MBAs). 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 forego 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, it has not reached this point quite yet.
Until society sees fit to legislate otherwise (which, DrRich supposes, could happen as early as the next president’s administration), 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 retainer practitioners.
One last word of advice for dermatologists: Have fun with your Botox clinics, fellas, but please don’t become too invested in them. Injecting Botox is not exactly cardiac electrophysiology. This is definitely a shallow-moat 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 - but do something that will provide you with a Plan C. Because Plan Botox is definitely a high risk endeavor over the long term.
Is Treating Cancer Worth It?
July 24th, 2008 by DrRich
Yesterday, Jacob Goldstein of the Wall Street Journal Health Blog pointed out the financial dilemma that has been created by evidence that a new cancer drug, Nexavar, is effective in treating liver cancer.
Most liver cancers are particularly impervious to chemotherapy, and until Nexavar came along no chemotherapy had ever been shown to significantly prolong survival. So when Nexavar improved the overall survival of a subset of patients with liver cancer in a well-designed randomized clinical trial (RCT) last year, the FDA (recognizing a true breakthrough when it sees one) quickly approved the drug.
The problem? Nexavar costs over $5000 per month. That, DrRich points out, is even higher than your average monthly health insurance premium. This means that any insurance company (or government) that agrees to pay for Nexavar is going to be out some big bucks.
(The good news for the payers, if there is any good news, is that Nexavar only prolongs survival by an average of three months, and the one-year survival of a population of patients with liver cancer on Nexavar is still less than 50%. Just think of the damage if Nexavar prolonged survival by several years!)
The economic question created by drugs like Nexavar - which result from extremely sophisticated and costly research and development processes, and whose benefits are undeniable but perhaps marginal - is likely to be asked several times over the next few years. We are also hearing those questions expressed, for instance, regarding the drug Avastin, which is used for lung, colon and breast cancer. Like Nexavar, Avastin has clear-cut and undeniable benefits that have been proven in RCTs. Like Nexavar it is very expensive. And also like Nexavar the duration of its benefits are measured in months, not years.
The form this economic question usually takes is: Should we really pay for extremely expensive cancer drugs like this when the expected benefit is so transient? While DrRich does not pretend to have the best answer for this question,* he will make two observations.
First, the reason it is so difficult to answer questions like this is that we in America (citizens, the government, and the insurers) refuse to acknowledge that there are limits to what we should expect from our healthcare system. We expect to receive any bit of healthcare that offers even a possibility of benefit, even if that benefit is likely to be marginal or transient. We expect our researchers to work day and night to cure every disease, no matter how rare, and we become indignant when progress does not seem rapid enough for our particular disease; indeed, death itself is merely a manifestation of insufficient research. In other words, where healthcare is concerned, there are and can be no limits.
Given this “no limits” paradigm, when our society is faced with the inescapable need to ration healthcare, that rationing can only be done covertly. There’s no other way to do it.
And under covert rationing (whose very purpose, again, is to preserve the illusion of “no limits”), there’s simply no mechanism, or even justification, for addressing questions like the one raised by Nexavar and Avastin. Our procedure is: we do the RCT, and if the RCT shows any measurable benefit, we pay for it. End of story.
So the insurers and the feds won’t be able to base their payment decision on some objective and transparent cost-benefit analysis for Nexavar, evaluating where this analysis falls in relation to all the other cost-benefit analyses they perform for all the other forms of therapy. Rather, they’re simply going to have to announce they’re paying for it. They have no other choice, because to do otherwise would question the “no limits” paradigm.
And then they’ll perform the unavoidable rationing by some covert means probably having nothing whatever to do with this particular therapy, or of any particular therapy, but rather, according to whatever means they can get away with, wherever in the healthcare system and with whichever patient that might be. That’s the job we’ve assigned to them. And they’re very good at it.
Second, the financial questions raised by Nexavar, Avastin, and similar therapies point out yet again that the Axiom of Industry often invoked by healthcare policy experts - that is, that improving quality will always reduce cost - simply does not work in healthcare. There are many, many times when achieving the best possible clinical outcomes (i.e., optimizing quality) greatly magnifies the cost of medical care.
The real problem with Nexavar and Avastin is not that their beneficial effect is just transient. That fact, to be sure, gives insurers and commentators a convenient handle, some basis for whining about these drugs that will engender sympathetic murmurs from certain quarters (though, as we have seen, it will ultimately not get them out of paying for them). But it’s not the problem. Indeed, the fiscal challenge for the payers would be much worse if these expensive drugs resulted in very prolonged survival. The real problem is that some of the stuff that works really well in healthcare is just really expensive, you see, because a lot of expensive research and technology went into developing and producing it. It just costs a lot.
So when some expert comes along and tells us that achieving a cost savings resulting from some brilliant new initiative - such as pay for performance, disease management, medical home, etc., etc. - will necessarily and directly yield an improved quality of care from that same initiative, we can immediately dismiss him or her as being either disgracefully ignorant of his or her chosen field of study, or disgustingly deceitful. In DrRich’s experience, the odds of any particular policy expert being disgraceful vs. disgusting is roughly 50-50.
* He does, however, pretend to have a transparent and equitable process for getting to a reasonable answer, which can be found in his book.
How Covert Rationing Precludes Efficiency
July 3rd, 2008 by DrRich
(Don’t forget to check out the Independence Day version of Medical Grand Rounds.)
Depending on which news source you read, physicians either are or are not about to get hit with a 10.6% pay cut from Medicare. (The actual outcome of the pay cut kerfuffle, some say, will depend on how many Republican Senators are buttonholed by how many American doctors at July 4 picnics.)
Many people have formed rather firm opinions on this matter. Physicians, for instance, mostly disapprove of the pay cuts. Others (most often non-Medicare-aged non-physicians with what is termed today a “progressive” outlook) feel strongly that doctors are among the most coddled and advantaged groups in the land, and that a modest sacrifice like this pay cut is the least they ought to be willing to offer for the public good. And of course, DrRich himself has an opinion on the matter, which will be well-known to most readers of this blog.
But on the other hand, most Americans haven’t really given it much thought. After all, most Americans are not doctors, they’re not on Medicare, they’re not politicians, and they’re not sick. Besides, some have suggested, the Bible-thumping, gun-toting masses are too disaffected with such concerns as the cost of gasoline, food prices, job security, health insurance, and the 15 (or 16 - one loses count) consecutive losing records of the Pittsburgh Pirates, to be able to concentrate on the truly lofty questions. Furthermore, it is commonly believed by well-educated (and especially progressive) persons that the great unwashed are just a bit too dim to understand the really important issues, and so must be reassured (and led along) with easy-to-digest, 10-second “executive summaries,” which can be repeated over and over and over, as needed. So, for instance, we can’t let a few greedy doctors and fat cat Republican Senators destabilize Medicare.
DrRich, on the other hand, who was himself held in captivity by two of these Bible-thumping, gun-toting hoi polloi for the first 18 years of his life before escaping to more enlightened environs, grudgingly came to realize they weren’t so dumb after all. Indeed, in comparison to many of the Harvard-educated Top Scientists and Top Doctors with whom DrRich (who did not go to Harvard) has had the honor of working, Mom, Dad and the guys in the steel mill (with whom DrRich also had the honor of working, back when America still had steel mills) displayed a very comparable degree of innate intelligence, and a far superior degree of general wisdom and common sense.
But not even Dad (the smartest man DrRich ever knew, uncommonly smart even for a steel worker) could have figured out how doctors are getting paid today, or what’s up with the projected physician pay cuts. (He would have easily brushed aside the assertion that doctors themselves ought to embrace the cuts out of a sense of altruism, or alternatively, guilt.)
The sad fact is that anyone who actually tries to look behind the headlines to figure out why physicians are (or are not) about to get hit with a 10.6% pay cut by Medicare will quickly be swept away by a maelstrom of tangled laws, policies, regulations, interpretations, guidelines, secret committee proceedings, quid pro quos, tit for tats, and “unintended consequences” of both varieties (i.e., the actually unintended ones and the secretly intended ones), that surpasseth all understanding.
Go ahead, try it yourself.
First, DrRich recommends you study the Happy Hospitalist’s latest exposition on how doctors actually get paid. It is the clearest explanation DrRich has ever seen. But even though Happy has taken very great pains to simplify the processes involved, in order to make them remotely understandable (and to such effect that he deserves a Pulitzer, or whatever the blogging equivalent may be), their complexity is breathtaking. Trying to explain how physicians get paid is akin to explaining how one achieves the mystic vision of the Great All; one can come close to the truth with the use of language, symbols, graphics, analogy, starvation, exposure to the elements and controlled breathing, but one must actually experience it to appreciate the essential wonder and transcendent awe.
Then, for a clear explanation of how changes to physicians pay are accomplished, DrRich insists you deconstruct Robert Laszewski’s article in Health Affairs. This is merely a description of Congressional procedure, not really that much more complicated than most things Congress does, and is necessarily much simpler to follow than the Byzantine convolutions tackled by the Happy Hospitalist. But still, it is fairly frightening that any aspect of America’s healthcare is decided in such a manner.
However, to really begin to get a general idea of the complexity of the whole system, one must synthesize these two articles - the process for regulating the system of physician reimbursement (Laszewski) and the system of reimbursement itself (Happy.) By “one,” DrRich is referring to you, the reader, as it is far beyond the poor abilities of DrRich to do so himself.
Don’t feel badly if you can’t synthesize this mess, either. For in truth, the physician reimbursement system is not meant to be understood by mortal man.
And that’s the point.
It turns out that this incomprehensible physician reimbursement system was set on its current path by one simple desire: to force doctors to covertly ration healthcare. As Laszewski explains in another article,
The idea was to set an “affordable” physician cost trend and when real costs exceeded that level Medicare would compensate for it by cutting future fees. The. . .message to doctors was simple: If you spend too much the Medicare program will compensate by cutting your fees in the future to balance things out. The objective was to give physicians a reason to control their costs.
Yes, that’s right. The original purpose behind this whole mess was to induce physicians to stop spending so much of Medicare’s money on patients’ medical care.
But when you set out to do such a thing, you can’t just come right out and say so, because that would be admitting to rationing. Instead, you’ve got to hide your real purpose in soothing language (generally it’s best to employ irony, and talk about improving efficiency and quality), and in bureaucratic processes that are so convoluted that the casual observer (or even the serious investigator) will not be able to discern their real intention.
Things get bad enough, as DrRich has described numerous times, when the bureaucratic entity running the covert rationing effort is a private insurance company.
But to really appreciate the potential for the opacity, complexity, and inefficiency demanded by covert rationing, one must study the government’s efforts in this arena. To the mere goal of profit which is the lifeblood of any company (too often fueled by excessive greed, one must admit), add the much stronger and additional aims of power and influence that fundamentally motivate our politicians, regulators, administrators, and others too numerous to mention who work for the government. Then stir in the absolute need to make convoluted deals, compromises and concessions with sundry interest groups and diverse colleagues and acquaintances, influences that may or may not have anything whatsoever to do with healthcare. Pretty soon you have the kind of “system” that is partially explained by a synthesis of the exertions of the Happy Hospitalist and Robert Laszewski.
The current physician reimbursement system is emblematic of what we might expect if we turned the entire healthcare system over to the government, and those who rail against such a single-payer system ought to use this example as an object lesson. For those who favor a single-payer system, however, such examples are simple to counter with illustrations of the egregious and heart-rending abuses perpetrated by private health insurers.
This is all to say that the real issue is not so much with the government or with the private insurers. Whatever travesties these entities perpetrate simply follows from the job we’ve all given them, which is, to ration our healthcare covertly. Covert rationing is rationing by whatever means you can get away with, and so utterly requires head fakes, misdirection, systematized inefficiencies, complexity, delusion (of self and others) and flat out lies. These things simply cannot be accomplished in a system characterized by transparency and smooth efficiency.
So if we’re going to continue rationing healthcare covertly, it really doesn’t matter all that much whether the rationing bureaucracy is controlled by the feds or private insurers. As the (other) Poet says, Fire or ice; either will suffice.
Medical Grand Rounds, Vol 4, No. 41
July 1st, 2008 by DrRich
Welcome to Medical Grand Rounds, Volume 4, Number 41, July 1, 2008. This week, bloggers from across the Internet have submitted articles that will help us celebrate the 232nd birthday of the United States of America. Their patriotic postings, organized according to their relationship to the Founding, follow:
Lists of Grievances
Annie at Home of the Brave sets the tone for this week’s Grand Rounds. She does a brilliant job showing what the Founders might have said about the current state of the American healthcare system, in What They Were Saying: A Riff on the Declaration and Resolves of the First Continental Congress. The First Continental Congress, of course, met in 1774 to petition King George for a redress of grievances stemming from the Intolerable Acts. The King rebuffed their petition and a shooting war broke out the following year, which led to, well, quite a bit. (Faced with their own intolerable Acts, many doctors, in stark contrast to the Founders, simply keep their heads down and continue making those little marks on their Pay For Performance checklists.)
Ian Furst of Wait Time & Delayed Care is Canadian and knows something about healthcare and the bureaucracy (not that doctors in the U.S. have any excuse not to know the same thing). Ian analyzes the results of England’s 4-hour ER wait-time guarantee, and shows once again how bureaucrats tweaking one variable in a complex system always manage to create interesting unintended consequences. But, since these unintended consequences will always require further bureaucratic activities in order to produce corrections, they guarantee perpetual growth of the bureaucracy, and thus are seen, by the people who really matter, as exceedingly good things.
Speaking of the proper limits of government, Doc Gurley considers, in her post, Hope and Death, the implications of the California Assembly’s latest bill, essentially requiring doctors to tell patients when they are terminally ill. This information, no doubt, would substantially lower patients’ expectations, and patients with low expectations can be managed very cheaply. (Which explains the legislative impetus to become involved in such matters.) But as Doc Gurley points out, the definition of “terminally ill” is often in the eye of the beholder, and the definition favored by those running the healthcare budget may be quite different from the definition patients (and doctors, if left to their proper medical functions) would favor. Doctors not wanting to break the law (or expose themselves to yet another, particularly promising, form of healthcare fraud) will predictably begin shading the definition of “terminally ill” toward the cost-saving side, i.e., making the determination somewhat earlier than traditional (or proper). DrRich predicts that our faithful public servants will soon take note of the prolonged anguish that will ensue as a result of the newly prolonged (by legislation) duration of terminal illnesses, and their bureaucratic compassion will move them to legislate a mitigation; namely, a law requiring the easy availability of physician-assisted suicide.
The Happy Hospitalist this week offers one of his patented, in-depth analyses of the utter mess that Medicare has become, in This is What You Voted For. For a system that produces the exact opposite of what it says it wants to produce, you can hardly beat Medicare. Happy says, “Look out America, get ready for even lower access to cheap effective [primary] care and a highly expensive and wasteful proceduralization [by specialists] of your friends and family. . .Well America, this is what you voted for. I hope you’re ready to live with the consequences.” Taking into account the bizarre incentives, Byzantine inefficiencies, and systematized grievances that are provided in such luxurious abundance by Medicare, Happy (and DrRich) can only marvel in dazed wonderment that anyone thinks that turning the whole healthcare system over to these people is a good idea. Imagine our honored forebears clamoring to turn over the entire colonial economic system to the perpetrators of the Stamp Act!
And anyone who still thinks any government knows how (or can know how) to run a healthcare system should become a regular reader of Dr. John Crippen’s NHS Blog Doctor, to get a taste of what healthcare across the pond is really like. His recent posting, The Rise of the Healthcare Professionals, describes just a few examples of the systematized dumbing-down of healthcare that has accompanied England’s NHS, and will accompany any system in which codified policies, procedures, and guidelines, handed down from on-high and strictly enforced, replace genuine medical thought.
Inalienable Rights
DrRich has always been amused by those boutique diseases that doctors occasionally invent in order to justify new avenues for payment. Psychiatrists (in DrRich’s humble opinion) have been particularly adept at this game. Dr. Shock MD PhD gives us his opinion on the latest such neo-diagnosis - Internet Addiction. Dr. Shock, we are happy to note, is not enamored with this new disease, and to his very great credit finds in America’s founding documents an inalienable right to the Internet. All self respecting bloggers must unite against declaring as a disease the robust appreciation of the Internet!
The anonymous blogger who writes How to Cope With Pain wonders in Can I Still Blog? whether blogging is an inalienable right - and concludes that while it may be a right, the fact that something is a right does not necessarily relieve you of the attendant risks or consequences. So that’s why all those other physician-bloggers choose to remain anonymous! Is it too late to inform you that DrRich is actually a 58-year-old housewife from the upper Midwest who learned everything she knows about medicine from Dr. Kildare reruns?
Alvaro at Sharp Brains talks about the inalienable right of men and women to own functioning brains - and what they can do to keep them - in Why We Need Walking Book Clubs.
Theresa Chan at Rural Doctoring tells a painful story, in Another Reason Why Healthcare is Going Down the Toilet, documenting how some patients (and patients’ families) feel they have an inalienable right to all the time and toil they desire of physicians, and for free.
The Spirit of the Individual, That Which Made America Great
Rob, at Musings of a Distractable Mind, shows us that the independent, creative spirit that made America what it is remains alive and well - even in PCPs! DrRich has long maintained that PCPs need to think outside the box in order to salvage their profession, and in What are You Going to Do? Rob demonstrates thinking that is, uh, way outside the box.
Over at Insure Blog they’re talking about another aspect of the right to fend for yourself - this time, using a patient’s own cloned immune cells to treat cancer. This research, which comes from the UK, is not funded by the National Health Service, nor has the NHS expressed the least interest in it. So, one might say, the British government is keen to remain “independent” of potentially expensive cancer cures. Read about it in Interesting Cancer News.
David E. Williams at the Health Business Blog tells us about an idea whose time has surely come - enticing patients to take their medication by rewarding them with chances in a lottery. Now, what can be more American than that? Go read You gotta play to win.
Kim of Emergiblog reminds us in Give Me Empathy, or Give Me . . . Another Nurse, how, when we are sick and frightened, nothing can soothe us like the presence of a confident, knowledgeable and empathetic nurse. The continued empathy of nurses is quite remarkable to DrRich, who notes that nurses are under as much stress from the bureaucracy as are doctors. Add to that the stress from being expected to follow orders from those harried, frustrated, angry, not-always-clear-thinking doctors, while still doing the right thing for the patient - dual responsibilities that are not always 100% in alignment. Continued empathy under such challenging conditions can only be attributed to individual character and dedication.
Kerri of Six Until Me reminds us in My Own Shoes that knowledgeable, intelligent and rational patients will always take doctors’ recommendations under advisement, but may ultimately decide that their own personal situation is best served by some deviation from those recommendations. Such patients are not being “non-compliant;” they are considering the doctor’s advice within the context of the totality of their lives (which will always include data their doctors can never fully understand), and exercising their own individual judgment.
Christian Sinclair at Pallimed reports on the practice of hospice medicine during the ongoing Midwestern floods. His report reminds us of America’s greatest asset - the dedication, ingenuity and spirit of individual Americans - which is always most impressive under the toughest of circumstances.
Christine of You Don’t Look Sick tells us how patients can take a major step toward declaring their own independence from a hostile healthcare system - by taking charge of their own medical records. Great advice for any patient.
Standing Up To Powerful Authorities
Dr. Mintz takes on the all-powerful popular media in telling us the truth about the 8 drugs that doctors wouldn’t take. It is very popular to bash the drug companies these days, and accordingly, any negative news about (expensive) new drugs is invariably hyped far beyond any objectivity. DrRich would likely say that this behavior is just another example of covert rationing. But Dr. Mintz more usefully provides the objective truth about these “never drugs.” Perhaps, as a follow-up, he should write about the 8 sources of medical news that doctors (at least the smart ones) wouldn’t read.
JunkMD over at Progress Notes sounds like he’s just about ready to tell the feds what they can do with their latest pay cut. In They Just Don’t Get It, he is fed up both with his Medicare-age Senators and with fellow citizens who expect him to just sit there and take it. Maybe, he allows, it’s time to consider retainer medicine. “Opponents of this model wonder who will see the patients who can’t afford a retainer physician. Well, if none of us are in business, it won’t matter.” That sounds about right to DrRich.
DrRich his own self offers an alternative (and most uplifting) explanation for the fact that doctors apparently owe the IRS multi-millions of dollars in unpaid taxes. Rather than merely being tax cheats, perhaps these physicians are emulating their forebears who nobly defied oppressive Acts of Parliament by throwing tea into Boston harbor. But then again, perhaps not.
The Freedom From Misinformation Act
Dean Moyer of The Back Pain Blog helps one reader declare her independence from misinformation by answering the question Can Herniated Discs Really Heal?
Dr. Paul Auerbach at Medicine for the Outdoors tells those who are exposed to the smoke from wildfires (now raging in California) how to stay healthy. Being aware of oncoming threats in this case is a bit more complicated than “one if by land, two if by sea,” but is no less important.
When DrRich was a medical student, the only decent doctor show on TV was Marcus Welby, MD - a series that was heavy on personal interaction but weak on medical information. So cracking the books was the only good option for learning a little medicine. Today, medical students have many more options. Monash medical student, for instance, is fighting misinformation (his and ours) by reviewing episodes of House.
David Harlow of HealthBlawg reports on the launch of the Massachusetts eHealth Collaborative’s latest Health Information Exchange (HIE). An HIE is more about interdependence than independence, but then, our Founders also banded together (vowing to hang together so as not to hang separately), in their struggle for autonomy.
And Dr Penna reports on new information on Genetic Risk Factors for Alzheimer’s Disease. If you decide to get the test, don’t tell the government or United HealthGroup.
The Obligations of the Individual in a Free Society
Marshall, the Episcopal Chaplain at the Bedside, reminds us in Returning to those Hard Conversations that doctors caring for the terminally ill should more often just say the plain truth, even when it’s painful (for the doctors) to do so.
Dr. Val and the Voice of Reason informs us that it’s plain to both the Surgeon General and to any beat cop that “most people just don’t know what it means to be a good citizen anymore.” Read her plain-spoken interview with Sgt. Zlotkus here, then go do the right thing.
Tories
Some, when a growing conflict reaches the point of no return, will always side with the more powerful disputant. In the Colorado Health Insurance Insider, Louise writes about why doctors are unhappy, and postulates that as a result many physicians now say they are in favor of universal, single-payer (i.e., government) healthcare. DrRich simply notes that after the American Revolution, thousands of Americans who had favored continued rule by the King moved to Canada and got what they desired; and finds it interesting that today’s Americans who want the sovereign power to take over healthcare could do exactly the same thing (if they were to lose the “healthcare wars,” as unlikely as it now may seem), and with precisely the same result.
Am Ang Zhang of The Cockroach Catcher blog tells us about the systematic abuse of the diagnosis of Post Traumatic Stress Disorder by “an alliance of antiwar psychiatrists, VA hospital administrators, and patients who never saw combat or even Vietnam service but found that reciting the PTSD symptoms would result in the awarding of disability payments.” Read about it in PTSD: Diagnosis du Jour. Even John Adams has an opinion about this one.
Picnic Advice, or Don’t Be Stupid
RLBates of Suture For a Living wants to make sure we have a happy 4th. She posts again this year on fireworks safety - a matter whose importance she, a plastic surgeon, unfortunately knows all about.
The Samurai Radiologist at Not Totally Rad offers advice on keeping kids from ingesting foreign objects in Coming Soon to a Child’s Stomach Near You. SR helpfully reports on a missive he received from a concerned parent who is dismayed by the existence of such a thing as Kellogg’s Lego Fruit-Flavoured Snacks: “I just spent the first three years of my son’s life trying to get him not to eat blocks, and now you’re telling him they taste like [fornicating] strawberries. Thanks a lot assholes.” Picnic advice like this you can’t get just anywhere.
What Doesn’t Kill You Will Make You Stronger
Americans have learned repeatedly that adversity produces strength. So, if the rising prices of food have you down, Walter, at Highlight Health, urges you to be of good cheer! In The Upside of High Food Prices he describes how more people are eating local produce - and eating healthier. He neglects to point out (though DrRich will kindly take up the slack) the other problem caused by cheap food that is now being mitigated. We refer, obviously, to the fact that cheap food is the chief source of what has become the latest scourge-of-society: obesity.
Service and Sacrifice
Fighting for what you believe in is always costly, and the cost is never more apparent than in Healthline’s posting on Suicides in US Troops. If you know a serviceman or servicewoman this holiday, let them know how much we all love them and value their service and sacrifice.
The Most Important Aspect of Any Holiday
Bongi at other things amanzi offers us the sad and most affecting story of little k. On this holiday - or any holiday - the best lessen we can take away from k’s story is to gather around us those we love, give them a hug, then count our blessings and thank God for every one of them.
Next Week’s Grand Rounds
Next week Grand Rounds will be hosted by The Blog that Ate Manhattan.
Why Backdating Stock Options Is Completely Understandable
June 4th, 2008 by DrRich
The Wall Street Journal Health Blog reported yesterday that Bill McGuire, the former CEO of UnitedHealth, did not know that backdating stock options was wrong. McGuire was eventually fired for his unfortunate backdating activities.
According to the WSJ, in the way of explaining how McGuire might be unaware that backdating stock options is frowned upon his attorneys state (in a brief filed on his behalf in a shareholder lawsuit), “Dr. McGuire has no formal training or degrees in finance, accounting or law. His only professional training is as a medical doctor with a specialty in pulmonology.”
The WSJ Health Blog, affecting its usual snarky tone, scoffs at this: “The Health Blog has no formal training in pulmonology, but the sums involved in this case do make us gasp for breath.” The value of McGuire’s backdated stock options, they go on to say, has been estimated at $1 billion.
It will undoubtedly be a great comfort to Dr. McGuire that DrRich now wishes to come to his defense.
Yes, it is clearly absurd for McGuire to argue that, because he’s just a dumb pulmonologist, he didn’t know that backdating was wrong. Every doctor, even radiologists*, understand that backdating important documents is wrong and probably illegal.
What the WSJ, and more importantly the litigious and thankless shareholders of UnitedHealth, fail to realize is that the skewing of McGuire’s moral compass has nothing whatever to do with his original profession or training. Rather, it is an essential skill required by anybody running a health insurance company.
These outfits, which exist to covertly ration healthcare, have got to do everything they can possibly get away with to avoid subscribers who are ill or might become ill, who are economically disadvantaged, or who are particularly demanding. They are obligated to do whatever it takes to deny coverage retrospectively to legitimate subscribers who have developed expensive illnesses. In a thousand ways they have got to play fast and loose with the rules and - more to the point - with documents. In fact, if the purpose of documents is not to manipulate the facts to the company’s best advantage, then what earthly good are they?
Once McGuire became the CEO of such an organization, manipulating the truth, largely through the creative use of documents, must have become second nature. And he must have become very good at it. (Otherwise why would the shareholders award him all those stock options?) Getting documents to say what you need them to say would become more than second nature to such a one; it would become why God put him on the earth in the first place.
So when a CEO of a big health insurer is given yet another document on which changing something as simple as a date will significantly improve the bottom line, it must have been unthinkable - nay, unethical! - for him to not simply go ahead and change the date.
The WSJ can laugh all it wants at McGuire’s plea that he didn’t know backdating was wrong. And the shareholders can profess as much outrage as they please. One might as well rail at a rigorously trained pit bull which, in the frenzy of a death match, clamps its jaws on the calf of a spectator who has inadvertently strayed too close to the action. If you’re going to employ such single-minded beasts, be careful of the objects you place before them.
DrRich hopes that it provides Dr. McGuire with a touch of consolation to know that at least one compassionate observer buys his protest of innocence without any reservation whatsoever. Indeed, DrRich would be far more disturbed by the notion that a CEO of a successful health insurance company might actually understand right from wrong, yet still do his job anyway.
* Cardiologists (like DrRich) and radiologists are traditional enemies, engaging as they often do in turf battles over medical procedures, promulgating dueling guidelines, and the like. Consequently, for a member of one group to impugn the native intelligence of the other, as DrRich has done here, is a revered and honored pastime for both of these specialties. So no one need take offense at DrRich’s gratuitous slur of radiological aptitude. Anyone who does is as thin-skinned as a pathologist.
Vital Info On:
****
Fixing American Healthcare
Best Book of the Year - Politics and Society
****
"Gin-clear specifics propped by ample research, and an abiding sense of decency" - Kirkus
"A fine blueprint for radical healthcare reform." - Smartmoney.com
Fogoros has a unique communication approach that reaches down to the layman." - Reader Views
"This book is a must-read" - the Dr. Wes Blog
A damn fine book" - Medinnovations Blog
Buy Fixing American Healthcare:
Categories
- A right to healthcare (4)
- An Introduction to Covert Rationing (6)
- Cardiology Topics (3)
- Evil Drug Companies (3)
- Fixing American Healthcare (13)
- Gekkonian Rationing (16)
- General Rationing Issues (42)
- Guidelines, Abuse of (6)
- Healthcare economics (15)
- Investment “advice” (2)
- Medical ethics (4)
- Medical malpractice (2)
- New business models for healthcare (8)
- Primary Care in America (21)
- Uncategorized (5)
- Wonkonian Rationing (17)
Archives
