It’s the dog days of what seems to have been an unusually hot summer (though DrRich does not know whether it has been sufficiently warm to affect the global cooling trend we’ve been in for the past decade), and as is all too common at this time of year, we are seeing extraordinarily heartbreaking stories, (like this one), about healthy, robust young athletes dying suddenly on the practice fields.

Most of these tragic sudden deaths are due to a heart condition called hypertrophic cardiomyopathy. Hypertrophic cardiomyopathy often does not produce any symptoms prior to causing sudden death. But it can be easily diagnosed, before exercise-induced sudden death occurs, by screening young athletes with electocardiograms (ECGs) and echocardiography.

A couple of summers ago, the New York Times wrote about such an athletic screening program at the University of Tennessee. Based on the U of T’s results, “Cardiologists and other heart experts say that the screenings could help save the lives of the 125 American athletes younger than 35 who die each year of sudden cardiac death.”

The reason this routine cardiac screening is not widely used is because of the expense. Making the very conservative assumption that 1 million young Americans participate in athletic competition each year, and that (as the Times reports) the average cost of screening is $1000, then screening would cost us about $8 million to save one life. That’s pretty a steep cost-effectiveness challenge by any standard.

But Dr. Douglas Zipes (the perennial New York Times expert on matters cardiac) speaks for many of us when he says, “If it were my son playing ball, I would like him to have an echo, even though it is cost inefficient.”

In truth, the cost-effectiveness analysis here presents a problem only because the kind of screening being used is judged to be a medical service, and thus ought to be paid for through some centralized pool of money (whether the pool is controlled by insurance conglomerates or the government).

If we were to do a similar cost-effectiveness analysis on seat belts, smoke alarms, motorcycle helmets, or carbon monoxide detectors, we would reach a similar conclusion: Yes, those several hundred preventable deaths from house fires are indeed a tragedy, but we simply can’t afford to pay for smoke alarms for all those millions of American families, just to save those relatively few lives.

The difference, obviously, is that we don’t expect smoke alarms to be paid for out of public funds. We expect individuals to do their own cost-effectiveness calculation, and decide whether to buy smoke alarms from their own resources. Individuals tend to place a much higher value on their own lives than the value assigned to their lives by society (the self-assessed value of one’s own worth often approaching infinity), and therefore many people indeed find the cost-effectiveness calculation to come out in their favor. Thus, buying smoke alarms seems a reasonable investment for many individuals.

If Dr. Zipes wants his son screened by echo, by all means have it done. I agree it would be entirely worthwhile. But don’t ask me to pay for it.

It is especially noteworthy that the technology exists to place cheap, portable echocardiogram machines in the office of every primary care doctor, and every primary care doctor could be easily trained in less than an hour to rapidly screen athletes for hypertrophic cardiomyopathy. For probably less than $100, parents like Dr. Zipes could have their children screened with this kind of limited echo and an ECG at the same time they’re getting their flu shots.

But we can’t do this because a) professional groups like the American College of Cardiology will do everything they can to block the democratization of guild-based procedures like the echocardiogram (start-up companies that have developed such tiny, easy-to-operate echo machines have been very disappointed with the response of the cardiology community), and b) such screening is a medical service, and it’s generally acknowledged to be a travesty to expect (or, as DrRich points out, to allow) individuals to pay for any medical service themselves.

And if such obstacles result in the sudden deaths of a hundred or so young athletes each year (most of whom, by the way, are participating in pick-up or intramural sports, rather than the semi-pro variety we watch on TV every March), well, it’s too bad there’s nothing we can do about it.

DrRich entered medical school 40 years ago with every intention of becoming a general medical practitioner, and indeed he became one. But after only a year in practice as a generalist, he found himself so frustrated with the frivolous limitations and the superfluous obligations that even then were being externally imposed on these supposedly revered professionals, that DrRich altered course and spent several years re-training to become a cardiac electrophysiologist.

(Electrophysiology is a field of endeavor so arcane as to be mystifying even to other cardiologists. DrRich hoped that the officious regulators and stone-witted insurance clerks would be so confused – and possibly intimidated – by the mysterious doings of electrophysiologists that they would leave him alone. Happily, this ploy worked for almost 15 years.)

Still, DrRich has always held general practitioners (now called PCPs) in the highest regard, if for no other reason than these brave souls – unlike DrRich himself, who cut and ran at his earliest opportunity – have stuck it out.

But, as we all know, the practice of primary care medicine is today in crisis. Today’s PCPs are mostly looking to get out as soon as they can afford to do so, and today’s medical students are avoiding primary care in droves.

But not for the reasons most often claimed.  DrRich’s contention is that doctors are abandoning primary care medicine for reasons that actually have relatively little to do with low pay and high educational debt. The real reasons have much more to do with the fact that primary care medicine has been systematically and purposefully demeaned and diminished, to the point that it has become nearly an untenable choice for most doctors.

Accordingly, every now and then DrRich likes to point out – for the edification of his readers – some of the ways in which this fundamental devaluing of primary care medicine is being accomplished.

And so, here’s another reason it sucks being a PCP:

PCPs whose patients fail to quit smoking are now at risk not only of being publicly labeled as low-quality physicians, but also of being sued.

To see how this works, dear reader, DrRich asks you to place yourself, for a few minutes and for the sake of empathy, in the position of a modern American PCP.

As a PCP, one of the major banes of your existence is the struggle you must make during each and every “patient encounter” to get through a long Pay-for-Performance Checklist (different checklists for different patients, depending on their insurer). Completing these checklists, within the 7.5 minutes that have been graciously allotted to you for such encounters, is of course critical in order to demonstrate to the appropriate healthcare accountants the adequacy of your performance as a modern, high-quality American physician.

One item that invariably appears on each of your mandatory checklists, doctor, has to do with counseling your patient on smoking cessation. It’s likely you may have thought this to be one of the less objectionable mandates you must accomplish during each patient visit. After all, you can get through your well-rehearsed pitch on smoking cessation in 20 seconds or less (unless you are dealing with one of those rare patients who is actually serious about trying to quit), and thereby make up some of the precious time, from your 7.5 minutes, that you have already spent achieving some more challenging check mark (trying, perhaps, to talk a diabetic patient into taking the extraordinary steps necessary to get his hemoglobin A1c down that last 0.5% to target).

So: 20 seconds spent on smoking cessation. Check.

But whoa. Not so fast there, Dr. Welby.

Did you know there are guidelines for physicians on smoking cessation? Did you know that these guidelines were devised under the auspices of the federal government, by a committee of individuals who are anti-smoking zealots (not that there’s anything wrong with that)?

From this latter fact, of course, there are certain things you will already know about these guidelines before you ever see them. You will know that the guidelines must be very long and detailed and tedious, because a) they are federal guidelines, and b) they are devised by people whose one and only mission in life – a mission they clearly believe is far more important than, say, oil spills, terrorism, global warming, jobs, or achieving fine and durable erections upon demand – is to save the world from the scourge of smoking. And now, these zealots have been granted the authority (i.e., the federally-approved authority to generate medical guidelines) to make it your primary mission in life, too.

Now, doctor, have a peek at the actual guidelines, which you can find here. Notice, first, that the federal guidelines for physicians on smoking cessation are 196 pages long. Notice how they step you through the process of counseling, and then step you through each of the measures you must take in order to guarantee that your patient achieves total success. And notice that an early branch point in the process of counseling is the one where the patient informs you whether he/she is willing to go any further with efforts at smoking cessation; and notice further that when the patient concludes that he/she is indeed NOT willing to go any further, thank you very much for your concern, the guidelines do not relieve you of further immediate obligations – no – but instead specify additional interventions you must now, at this moment, embark upon with this unwilling patient, which are “designed to increase their motivation to quit.”

The brash sales techniques required of you by the federally-sanctioned smoking-cessation guidelines would embarrass even a telemarketer, or an annuity salesperson.

This, of course, is all to say: Your 20-second spiel on the evils of smoking just doesn’t cut the mustard, doctor. To really earn that smoking-cessation chit on your P4P checklist, you need to do a lot more than that. The 196 pages of deadly serious federal guidelines detail what that is.

Lest you are tempted to dismiss as an absurdity the expectation that you are actually supposed to cram 2 hours of anti-smoking counseling into a 7.5 minute patient visit, there’s one more thing you ought to know.

One John Banzhaf, Executive Director and Chief Counsel for Action on Smoking and Health (ASH), who bills himself as the “law professor who masterminded litigation against the tobacco industry,” is not taking lightly, doctor, your obvious laxity in following federal guidelines on smoking cessation. Accordingly, some time ago he sent letters to each of the 50 state health commissioners warning them that he will soon begin instigating medical malpractice suits, on behalf of smokers who continue to smoke as the result of their doctor’s refusal to follow federal guidelines to the letter.

Mr. Banzhaf informs the commissioners that “physicians are killing more than 40,000 American smokers each year by failing to follow federal guidelines.” That’s right, doctor, you’re killing them. (Cigarettes don’t kill people; people kill people.) Specifically he invokes your sacred obligation to “warn the smoking patient about the many dangers of smoking and provide effective medical treatment for the majority who wish to quit.” (Emphasis DrRich’s.) That is, it’s your job not just to counsel them and treat them, but also to see that they actually succeed in quitting. If you don’t follow this mandate, you’re killing them. And you must pay.

When the federal government takes the pains necessary to draft detailed management guidelines for physicians, guidelines that, if followed as written, will save tens of thousands of lives each year, then surely society has every right to expect you to follow those guidelines to the letter – and to save those lives.

This is such a brilliant scheme for ending smoking-related death and disability, one must wonder why it hasn’t yet been applied to other intractable medical problems. Just think of all the good that could be accomplished, for instance, by federal guidelines requiring PCPs to assure that each of their patients maintain an optimal body weight, follow an exemplary diet, exercise vigorously for at least an hour a day, maintain unfailingly positive attitudes, and work diligently at their allotted tasks each and every day (secure in the knowledge that adopting right thinking and right behaviors will be invaluable to our dear leaders, as they bravely go forth to assure the good of the whole).

In any case, doctor, consider these anti-smoking guidelines carefully next time you’re putting that little check mark next to “Smoking cessation counseling” on your P4P checklist, and ask yourself: “Have I really done all that I am obligated to do, under the law, to guarantee that this patient has lit up his last smoke?”

Making PCPs responsible for their patient’s personal choices and behaviors, of course, is a time-honored method of covert healthcare rationing. It gives doctors powerful incentives to invent mechanisms for avoiding patients who display obviously unhealthful lifestyles, thus making it relatively inconvenient for these patients to gain access to expensive healthcare services.

But more to the point of this post, it is yet another example of how micromanagement by politicians, activists and bureaucrats has come to infest the practice of primary care medicine, and to relegate PCPs to the diminished role of simply following the checklists continually produced by such as these. If this is what primary care medicine has come to at last, why would you expect anyone who has a choice to take such a career path?

DrRich, for one, does not believe the 10-15% increase in pay hinted at by Obamacare will change the calculus for PCPs very much, and in fact, if it does – given all that is being done to primary care medicine – we should all be very much distressed by the implications.

In this series of articles, DrRich reveals why the insurance industry supported Obamacare, how the industry supported Obamacare, and (most importantly) what that support means to Progressives who pine for a single-payer healthcare system, and to Conservatives who pine for the repeal of Obamacare.

Part I – Another Reason He Should Have Kept the Bust

Part II – Why the Health Insurance Industry Supported Obamacare

Part III – How the Health Insurance Industry Saved Obamacare

Part IV – What It Means That the Health Insurance Industry Saved Obamacare

Podcast:

In the past few posts (in particular, here and here), DrRich has shown why the health insurance industry embraced Obamacare, and indeed, took extraordinary steps to assure that Obamacare became the law of the land. This, of course, is especially interesting in light of the common perception that Obamacare constitutes a major defeat for the greedy health insurance industry. But the fact that big health insurance gave critical support to Obamacare is far more than merely interesting. It has major implications both to supporters of Obamacare, especially the ones who hope for an eventual single-payer outcome, and to opponents of Obamacare, many of whom hope to repeal it after the 2010 mid-term elections.

For the health insurance industry to have supported Obamacare, especially in the manner that it did, leads us to three conclusions.

First, while almost nobody realized it at the time, the passage of healthcare reform – in some form or another – turns out to have been inevitable. Quite simply, the insurance industry was telling us in every way they knew how that they just could not tolerate the status quo any longer. And since the insurance industry is critical to maintaining the status quo, then one way or another, the status quo had to end.

Second, the health insurance industry has just succeeded in demonstrating its great and continuing worth to the Progressive agenda, a fact that might make it more difficult than many think for Progressives to achieve their real goal – a single-payer healthcare system. If our Progressive leaders have been paying attention, the health insurance industry has taught them two important lessens in this regard.

The insurance industry has taught them that running the American healthcare system, especially under a covert rationing paradigm, is a messy, ugly and painful job, and further, that it is destined to turn out badly. This, indeed, is the chief lessen that the health insurance industry has learned over the past 15+ years. DrRich believes that many of the Progressives who are now in a position of leadership, and who are on the brink of achieving at long last a primary goal of the Progressive agenda – government control of healthcare – are aware of this fact. So they are probably not quite as self-assured about their ability to achieve healthcare nirvana, for instance, as the insurance executives were in 1994. They can see, from the experience of the insurance industry, that even draconian efforts to covertly ration healthcare are very likely to fail to slow healthcare inflation over the long term.

Furthermore, the insurance industry has taught them, if such a lesson was even necessary, just what a great boon it is to have at one’s disposal a ready villain, especially a villain which assumes the form of a business, and in particular a villain which is satisfied to play its assigned villainous role whenever called upon to do so. When things go south with Obamacare, as things will, it will go a lot easier for our Progressive leaders if they still have the insurance industry – even in a greatly diminished form – to blame. Having a foil to absorb the blame will not solve the problem, of course, but it will buy the Progressives more time, during which they can do what Progressives always do, and institute another round of “tough regulations” to hold the villains in closer check. So keeping the health insurance industry around, rather than going to a single-payer system, will indeed provide a critical level of additional insurance – albeit to our political leaders, and not to patients.

One need only look at the mortgage crisis to see another good example of the great utility of having an evil foil at one’s disposal. As readers may recall, the mortgage crisis resulted when the government instituted a free-wheeling easy-loan policy that defied every known rule of free markets, engaged Fannie and Freddie to make the easy loans, and then recruited private businesses to absorb, distribute and hide the risk. When the excrement predictably hit the fan, the investment banks (which, like the health insurance companies, did indeed behave very badly in response to fundamentally unsound governmnent policies) were offered up as the bad guys. It proved so useful to have serviceable villains during the mortgage crisis that the taxpayers were called upon to bail the villains out lest they disappear, and then, most recently, financial regulations were completely overhauled to make sure the villains will always be there. (DrRich calls this policy “Too Evil to Fail.”) In this way, Fannie and Freddie can continue making unsustainable loans, without ever having to take the blame for the consequences.

In other words, villains who reside in the domain of private enterprise are extremely useful to the Progressive program. The health insurance industry has just graphically demonstrated that it is every bit as helpful to the government’s takeover of healthcare as the investment banks were to the government’s takeover of the housing market. So DrRich, for one, bets that the health insurance industry will have a long – if unhappy – life as a government-regulated public utility, which can be called upon, whenever necessary, to display its fundamentally evil nature, in order to prove yet again that the problem is (even now!) not enough government regulation.

In contrast, once the government assumes full, direct control of healthcare (or any other aspect of the economy), then there will be nobody to blame but the government when things go wrong. (This is not strictly true. All-powerful authorities can always find somebody to blame. Historically, for instance, they often begin with the Jews, though today one must speculate that the obese will also be near the top of the list. DrRich, and, he suspects, most of his American Progressive friends, would much rather submit corporate villains to an *auto de fe* than go once again down this well-trod historical path.)

The role of Court Villain may not be exactly what the health insurance executives had in mind when they saved Obamacare, but since they had no choice in the matter, it will have to serve.

And finally, the third conclusion. Since the health insurance industry has been telling us that they are at the end of their rope, to the point that their best option was selling themselves out to President Obama and his ruthless refomers, then the idea that Obamacare can simply be repealed, or de-funded, or de-featured, or declared unconstitutional, so that we can just go back to the healthcare system we’ve had since 1994, is absurd.

Indeed, even though Obamacare is now law, the health insurance companies are by no means out of the woods. There remains a real question as to whether the provisions of Obamacare will be sufficient for the short-term viability of the health insurance industry.  Most of the provisions of Obamacare – in particular, the individual mandates the insurance companies are relying upon for their One Last Windfall – do not go into effect until 2014.

At least until then, the insurance companies likely will need to keep increasing their annual premiums at astronomical rates in the attempt to remain sufficiently profitable. Can the system sustain such increases until 2014?  Or, will the provisions of Obamacare have to be accelerated? Or, will Obamacare have to be revised, for instance, to add the much reviled (or much desired, depending on your political views) “public option?”

But while Obamacare may need to be accelerated or further radicalized, it cannot just be repealed. For the same reason that healthcare reform was inevitable, we can’t just go back. The insurance industry simply will not tolerate it.

What we all have to remember – and the main point of this series of posts – is that we can’t just get rid of Obamacare and go back to the way things were.  If we think we need to substantially change Obamacare, so as to shed ourselves of the extremely disturbing spectre of government-controlled covert rationing (which will be far more destructive than the insurance-company-controlled covert rationing we’ve painfully endured for 15 years), we’ll need to have another solution in hand.

DrRich, of course, knows such a solution, and he has described it in detail elsewhere.

__

Why Big Health Insurance Supported Obamacare

Part I – Another Reason He Should Have Kept the Bust

Part II – Why the Health Insurance Industry Supported Obamacare

Part III – How the Health Insurance Industry Saved Obamacare
________________________________

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:

As we have seen, the fact that the health insurance industry was going to support healthcare reform after the 2008 elections was a foregone conclusion.  The question was: How would the insurance industry support healthcare reform?

When the time came, the support the insurance industry gave to President Obama’s efforts to reform healthcare followed four simple rules:

1) Do not actively oppose Obamacare. In stark contrast to its behavior during the Clinton’s effort to reform healthcare in 1993-94, this time the insurance industry never engaged its vast public relations resources to stifle healthcare reform.  There was no Harry and Louise this time. (Actually, Harry and Louise – the original actors – did make a brief appearance, but now, like the insurance industry itself, they were older, wiser, and sadder, and this time they fully supported the proposed reforms.)

2) Submit quietly to demonization.  A key strategy of the Democrats in passing Obamacare was to remind Americans repeatedly that the for-profit health insurance industry is fundamentally evil.  This strategy was based on the time-honored precept that it is easier to get the unwashed masses to cooperate through hatred than through reason, and so, to gain their cooperation, one must give them something to hate. Obviously, this strategy meant that the health insurance industry had to accept its role as the bad guys in the reform debates without complaint, and without engaging in any serious self-defense.

3) Offer subdued public support to Obamacare. The AHIP (America’s Health Insurance Plans) issued public statements that cautiously supported President Obama’s healthcare reforms. But its support had to remain subdued and tepid, since Satan can’t be seen leading the hymns.

4) Whenever necessary, rise up and demonstrate to the world just how evil you really are. At the end of the day, this was the most important role the insurance industry played in advancing Obamacare. It was certainly their most active role.

It was not a difficult role to fill. Since 1994 the health insurers had engaged in the sorts of truly evil, inhumane, and reprehensible practices that are naturally engendered by covert healthcare rationing, and that harmed or killed many of their subscribers. The only difficult part was choosing which reprehensible behaviors to feature, and when to do it.

In at least two key moments during the fight over healthcare reform – June, 2009 and February, 2010 – when the proponents of reform felt their momentum lagging, the insurance industry intervened with gratuitous behaviors whose chief function was to remind Americans just how unremittingly wicked and inhumane they really are. In the second case, at least arguably, the insurance industry turned the reform effort from apparent defeat to almost certain victory. Indeed, it is not too much of an exaggeration to assert that, in the end, the health insurance industry saved Obamacare.

June, 2009: Say Hello To My Little Friend

The debate over Obamacare entered a new phase in May and June of 2009.  It was during those months that the opposition to healthcare reform found its voice, and it began to seem as if perhaps the Obama steamroller could really be slowed, if not stopped. People were even beginning to say that many Democrats in Congress, after getting an earful from their constituents when they held their summer town hall meetings, would abandon any idea of supporting President Obama’s healthcare reforms.

Supporters of Obamacare decided it was time to invoke the demons.  So in mid-June, the House Subcommittee on Oversight and Investigations called three health insurers to testify on the practice of rescission, and to face not only indignant Congresspersons, but also some of the people who had been personally harmed by their practices.

“Rescission” is when an insurance company voids subscriber’s health insurance (after happily accepting premiums from that subscriber, often for many years) once they get sick. Under some circumstances, rescission might be justifiable. It is legal and proper to cancel a policy if the subscriber is found to have purposely lied on the insurance application about a prior illness that is material to the current illness.

But health insurance companies for years have actively and aggressively practiced rescission on subscribers whose insurance applications contained inadvertent and non-material inaccuracies.  (Just to put it in perspective, this kind of bad behavior is to be expected under a system of covert healthcare rationing, which again, is rationing by whatever means you can get away with.)

Furthermore, the health insurance industry does not merely engage in occasional unfair rescission practices; it has industrialized the process. It employs health insurance detectives whose job is to comb the prior medical records of subscribers who are newly diagnosed with certain, expensive medical conditions, looking for even trivial discrepancies on insurance applications, which they can inflate to “fraudulent” omissions, thus voiding the policy. These health insurance detectives are paid by commission, according to how much money their efforts can save the company. Many of them find it a very lucrative career.

So, at the cost of perpetrating a bit of inhumanity, rescission can save insurance companies a lot of money.

Consider some of the individuals who testified in Congress along with the insurance companies that day

• A nurse in Texas had her insurance canceled after she was diagnosed with breast cancer because she had failed to reveal that, years before, she had consulted a dermatologist about acne.
• A man (whose surviving sister had to testify) had his insurance canceled before he could begin expensive cancer therapy, because he had not revealed (and indeed he had not known) that a prior CT scan had showed gallstones and an aneurysm – conditions unrelated to his cancer.
• A woman had her insurance canceled – and due to the rescission could not find replacement insurance – because she failed to reveal that, at one time, she had been on medication for irregular menstruation.

During the hearing, the three health insurance executives were caused to listen to these and other incredible stories describing some of the inexcusable pain, suffering and death their unfair rescission practices had caused, and then were forced to listen to withering commentary by stunned Republicans and Democrats on the Subcommittee, whose own investigation had found that the three companies on the docket had retrospectively canceled the policies of 20,000 sick subscribers over the past 5 years.

After these heart-rending testimonies and the blistering attacks from extremely angry congresspersons, the executives were challenged by Chairman Stupak (D-Michigan) to now commit to discontinuing the practice of rescission unless intentional fraud could be shown.

All three replied, in turn, “No.”

Such a reply, in such a setting, almost defies belief. The only possible explanation, in fact, is that the insurance industry was stepping up to the plate, and embracing its assigned role as the Evil One in the great healthcare debate.

Even the most stone-hearted insurance executive can see that canceling the health insurance of a newly-diagnosed cancer patient, because she’d forgotten she’d required acne medicine before the prom 20 years ago, is just a bit unfair. But how did these three executives react? They did not attempt to deny such reprehensible behavior, or to explain it, or to defend it.  They were simply defiant about it.

One is put in mind of Tony “Scarface” Montana, bereft of friends, family, allies and bodyguards (albeit because of his own actions), hopelessly surrounded by an army of heavily-armed assassins, screaming, “Say hello to my little friend!” then launching defiantly into a wild, bloody and spectacular suicide.

One cannot for a moment believe that that Richard A. Collins, chief executive of UnitedHealth’s Golden Rule Insurance Co., Don Hamm, chief executive of Assurant Health, and Brian Sassi, president of consumer business for WellPoint Inc., would have been stupid enough to publicly defy Congress over such an indefensible practice, if doing so was against their own long-term interests.  Appearances to the contrary notwithstanding, they were not auditioning for a remake of Scarface.

This is not how an industry behaves which wants to court the goodwill of Congress at a critical juncture in its life cycle. This is not the strategy of an industry that wants Congress to defy its own party’s President and defeat healthcare reform, or that is begging Congress to give them another chance to figure out how to bring healthcare costs into check. This is not the behavior of any industry that wants to elicit any sort of favorable action from Congress. Indeed, these executives would have seemed more sympathetic and deserving if they had proposed instead to place live puppies on a spit and roast them over an open fire during half-time at the Super Bowl.

There is only one explanation for their astounding public defiance on this matter. Which is, it must have suited their long-term interests.

Recall that at the time of this remarkable hearing, there was growing skepticism about President Obama’s healthcare reform efforts, not only on the part of Republicans, but also on the part of a critical minority of Democrats in Congress. And for the first time since the election, there was some question about whether his reform plan would succeed in gaining sufficient support.

What must the health insurance industry do in the face of this faltering support for its desperate end-game? It must act to bolster Obamacare.

In this light the stark, defiant, public “no” uttered by the three insurance executives makes sense. “Look at us,” they were saying, “See how evil we are! We are utterly devoid of human decency, ethical obligations, or a sense of fair play. If we behave this defiantly when we are in the position of mere supplicants to your eminences, just think how we will behave if you fail to rein us in with new reforms!  Abandon all hope, those of you who rely on us for your healthcare, and behold the congressional dogs that placed us in this position of power over your very lives!”

Given the headwinds the healthcare reform effort was to face during the next nine months, it is difficult to say with any certainty how much good the insurance industry did in June, 2009, when it took such an extraordinary step to remind Americans just how incredibly evil it is. But when the time came to help boost the President’s reform efforts, nobody can deny that the insurance industry stepped up and did its duty.

February, 2010: Raising Obamacare From The Dead

Things looked especially bleak for healthcare reform in early February of 2010.  The incredible, possibly Constitution-defying, machinations Congress employed in its desperate attempt to pass healthcare reform had disgusted a majority of Americans, and momentum was clearly shifting to the opponents of Obamacare. And when Republican Scott Brown incredibly won the Senate seat in Massachusetts, robbing the Democrats of their crucial, filibuster-blocking 60th vote, many thought healthcare reform was dead.

But then out of nowhere, in early February, Wellpoint’s California subsidiary, Anthem Blue Cross, announced it was raising its already-astronomical health insurance premiums by as much as 39%, a move that promised to greatly increase the number of Californians who are uninsured.

The demoralized Democrats in the administration greedily capitalized on this new opportunity.

Kathleen Sebelius immediately fired off a very public letter to the company, demanding that they justify this unconscionable rate increase. And Wellpoint, lustily assuming its assigned role as villain, was delighted to reply, equally publicly.

We’re in a recession, Wellpoint brazenly asserted, and in a recession, like it or not, people exercise their prerogative to drop their health insurance. The only people who don’t drop their health insurance are the sick people, or those who are likely to become sick, which means that our cost per subscriber goes way up. So naturally, we have to increase premiums. By a lot. It’s just business. That’s just the nature of our current, unreformed healthcare system. So choke on it.

Wellpoint was also kind enough to mention (for anyone dense enough to have missed the point) that the need for higher insurance premiums would be nicely mitigated if everybody was mandated by the government to purchase health insurance.

Wellpoint’s anounced premium increase immediately triggered great volumes of delighted outrage by thankful Democrats, who desperately needed a large dose of “evil insurance company” at just that time. Wellpoint’s action reignited the proponents of healthcare reform, who were inspired to remind all Americans that this is what would happen to everyone if healthcare reform failed, and the greedy insurance companies had their way.

Stunned Republicans, seeing their impending victory over Obamacare evaporating before their eyes, could only issue a few lame and uncomfortable attempts to diminish the significance of Wellpoint’s unfortunate action.  But to little avail. The momentum had shifted. At least arguably, it was Wellpoint’s decision to announce an unconscionable rate increase at this extremely critical juncture that put healthcare reform back on the road to adoption.

From a pure business standpoint, there was no good reason for Wellpoint to stir the soup at that moment. Wellpoint is the most financially sound private health insurance company. While its California subsidiary did lose money in 2009, overall the company performed quite well, and reported a very nice profit growth for the year. And with several of its competitors in trouble, Wellpoint stood to do comparatively well for the foreseeable future.

Furthermore, it has since been learned that Wellpoint’s math was bad. An independent actuary working for the California Department of Insurance reported on May 5, 2010 that the company had made “numerous errors” in calculating is rate increases, and further, that Wellpoint could cut its rate hikes substantially, and still meet its required 70% medical-loss ratio threshold.

It stands to reason that if Wellpoint really wanted healthcare reform to go away, they would have first checked their math before announcing seismic rate increases, and then, if such astounding rate increases were really needed, they would have waited a few months – while Obamacare died – before announcing their rate hike.

The last thing they would have done is to throw the reformers a critical lifeline just as they were going under for the last time.

In any case Wellpoint’s action, especially at that moment, seems entirely gratuitous. Wellpoint could only have chosen to do its demon dance, at such an inopportune moment, in order to revive Obamacare during its darkest hour.

And that’s precisely what happened.

In the final post in this series of articles, we will take a look at the implications of the insurance industry’s support of Obamacare, as we who find Obamacare less than desirable contemplate what we ought to do about it.
__

Why Big Health Insurance Supported Obamacare

Part I – Another Reason He Should Have Kept the Bust

Part II – Why the Health Insurance Industry Supported Obamacare

Part IV – What It Means That the Health Insurance Industry Saved Obamacare
________________________________

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:

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 they 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

Part III – How the Health Insurance Industry Saved Obamacare

Part IV – What It Means That the Health Insurance Industry Saved Obamacare

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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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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

Part III – How the Health Insurance Industry Saved Obamacare

Part IV – What It Means That the Health Insurance Industry Saved Obamacare

________________________________

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!

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!

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!

Many thanks to a loyal reader, Ivan from Montreal, for calling DrRich’s attention to a recent editorial in the New England Journal of Medicine, arguing for more dollars to go to “public health,” as opposed to “healthcare.” The editorial is by David Hemenway, Ph.D., director of the Harvard Injury Control Research Center of the Harvard University School of Public Health.

By “public health,” Hemenway appears to mean that branch of academics that deals with promoting the overall health of a community through organized societal efforts. Some effective public health efforts have included vaccination programs, improved sanitation, motor vehicle safety, draining the swamps, limiting public smoking, and the chlorination of drinking water. A few of these efforts have even been advanced by actual public health experts, such as those to which Hemenway refers.

Hemenway’s main argument is that society gets more bang for the buck with money spent on these kinds of public health efforts, than on money spent on healthcare for individual Americans, an argument which is almost certainly true.

But his conclusion, that the distribution of healthcare dollars should be adjusted accordingly, is spurious. All four of the specific arguments he gives to bolster his claim that public health is underfunded are insubstantial, and more importantly, the folks who have given us most of the wonderful public health benefits we all enjoy are actually not the public health experts whom Hemenway wants to fund.

First, Hemenway claims public health is under-funded because people are just too stupid to understand the importance of public health. Specifically, they are incapable of valuing and thus implementing actions whose benefits lie in the future (such as those provided by public health). Hemenway is quick to say that it is not peoples’ fault; they are built that way. He even gives a complex neuroanatomical explanation for the innate inability of folks to plan for the future.

So: This must be why Americans have never landed on the moon, and why they refuse to invest in cancer research, or to fund their 401(k) plans. As Ivan from Montreal points out, this must be why the great cathedrals were never built. Hemenway’s point here is so spurious on its face that DrRich must wonder if it reflects that baseline contempt for the mental capacity of the proletariat, which is so fundamental to Progressive thinking.

Secondly, Hemenway points out that the beneficiaries of public health (being the public) are not identifiable as individuals, and so we (the bovine masses) cannot bring ourselves to care about them, as we care about individuals such as, he suggests, Baby Jessica falling down the well. This additional deficiency of the proletariat puts public health at a major disadvantage.

It is indeed true that humans have more capacity to identify with individual stories than with “populations.” But this issue is not unique to the field of public health. Those raising funds for heart disease research, for instance, deciphered this mystery long ago – since statistics only gets you so far, you need to tweak potential donors’ emotions by advancing the story of the 12-year-old heart transplant recipient. If the academics in public health haven’t been able to figure this out – using the Baby Jessica story to advance their latest theories on well safety, for instance – whose fault is that? (If what Hemenway says is true – that the field of public health “relies almost exclusively on government funding,” that’s where the fault is. Being on the public dole greatly dulls one’s perceptiveness and creativity.)

Thirdly, Hemenway says, “in public health, the benefactors, too, are often unknown.”  That is, whereas medicine has its great public heros – Hemenway suggests DeBakey and Barnard – the great heroes of public health do not get their due. There are doubtless many heroes of public health – the inventor of the flush toilet comes immediately to mind – but unfortunately most of them remain anonymous. The flush toilet’s inventor, for instance, based on current archeological evidence, died in the Indus valley 4600 years ago. Indeed, many if not most of the truly impactful public health advances took place outside the ivory towers of the modern academy.

Hemenway struggles mightily to come up with an unsung hero for modern, academically-based public health, and – and undoubtedly wishing not to remind us of certain well-known, early20th century heroes of the academy who espoused eugenics as the most effective means of achieving public health  – offers up one Maurice Hilleman, who saved countless lives with his development of more than 30 vaccines. Now, DrRich completely agrees that Hilleman was one of the most important scientists of the 20th century, and probably was responsible for preventing more premature deaths than any other person in history, and, certainly, that he is an unsung hero. But it is a bit of a stretch for Hemenway to claim him for one of his own. Hilleman did his vaccine development as an employee of E.R. Squibb, and then, of Merck. That is, his research was funded by private industry, whose primary motive was filthy lucre. If Hilleman is a hero of public health (and DrRich agrees that he is), then his career is an argument for unleashing the capacity of the private pharmaceutical industry, rather than an argument for more government funding.

Fourth, Hemenway laments that public health efforts often meet with fierce opposition from well-placed interests. This is true. Limiting smoking in public places, for instance, required a sustained battle against powerful interests for decades. But here, Hemenway tips his hand a bit too much. He cites a study showing that having a firearm in the house is a risk factor for gun death, and offers up this rather obvious result to illustrate the important work which academic public health can offer, and to decry efforts to de-fund that kind of important research. Now, DrRich does not diminish the importance of research whose aim is to improve gun safety. But he does wonder why Hemenway could only come up with an example of productive research which is just a little more helpful than, say, a study revealing that automobile deaths are more frequent in the U.S. than in Romania (where ox-carts remain a chief mode of transportation). If DrRich were grading this editorial request for funding as a formal grant proposal, he would take points off for the effectiveness of the applicant’s (that is, academic public health’s) prior work.

Hemenway’s fundamental sin is conflating “real” public health with whatever the people with degrees in “public health” are doing. “Real” public health consists of flush toilets, water treatment, draining swamps, pest control, well-lit streets, and the like, and tends to have a lot more to do with good civil engineering and fundamental medical research than with “academic” public health.

Some of what the modern experts in public health are doing, DrRich suspects, is quite important and is worthy of funding. But just because the schools of public health split off from medical schools in the 20th century, and established their own academic fiefdom, and commandeered the name “public health” as their exclusive domain, they ought not commandeer the credit (as Hemenway does here) for inventing and building sewage treatment plants, vaccines, or side airbags. Most of the actual “stuff” that makes public health so effective comes from somewhere else. If there’s to be more funding, give it to the people and enterprises that actually invent and develop that stuff.

Call DrRich a cynic, but he suspects that schools of public health really want more money so they can publish academic papers that will justify – or demand – more invasive governmental action to control private behavior, for the good of the collective. For instance, while DrRich does not know anything about Hemenway himself, he notices that a major interest of his Injury Control Research Center is firearm injury. Nothing wrong with that. But he also notices that the Injury Control Research Center gets a big chunk of its funding from the Joyce Foundation, an organization with a strong, self-professed “anti-gun” (and not merely gun safety, or gun control) agenda. One might be forgiven for wondering whether one of the “public health” agendas of the Injury Control Research Center in this regard might be to help justify stiffer anti-gun legislation. Whatever you may think of stricter gun legislation, diverting healthcare dollars to support one side or the other of a fundamentally political issue does not seem like a good precedent to set.

Let the public health experts get their own funding. Dollars that people pay for health insurance – whether through direct premiums to insurance companies or through tax dollars to Medicare, Medicaid, and whatever else is coming down the pike – ought to go for individual healthcare, and not to any interest group that can assemble an argument that whatever it is they are doing benefits the overall health of the collective. After all, anybody – from gym owners to grocers to game manufacturers to medical bloggers – can do that.