Join the discussion on how we can fix healthcare.

A recent newspaper article reported that, instead of reducing Emergency Room visits, the self-styled Healthcare ‘Reform’ Act (HR 3590), will increase visits to these already over-burdened facilities. Washington’s prediction of reduced ER visits was another demonstration of magical thinking.

Small children are magical thinkers. Ask any psychologist, pediatrician or parent. Magical thinkers believe that because they want it or can conceive of it, “it” is so or will be so. The magically thinking child ties a cape on his back and KNOWS he can fly. When he jumps off the roof, he will of course fall, not soar like Superman.

Those in Washington – both Congressional leaders and the White House – are magical thinkers. Because they say it, “it” will be. If House Speaker Pelosi says that HR 3590 will save money, it must save money. If President Obama says that the Bill will increase care, reduce errors and improve quality, it will happen (because he said so).

The reason most adults do not don capes and jump off roofs is evidence. They may have tried it as a child and have the painful evidence in memory of a broken leg. They may read in the newspaper or see on TV the evidence of what happened to a child who tried it. They may simply consider the centuries old evidence about gravity and deceleration injury.

Is there evidence about healthcare, evidence that Washington ignored? Absolutely!

“HR 3590 will save money.” Every entitlement Program ever enacted has: a) cost more than projected, and b) spent money we did not have or do not have. No entitlement Program EVER saved money. There is overwhelming evidence to prove this.

“HR 3590 will provide care for 30 million uninsured Americans.” Is there evidence to confirm or refute this? Again, yes. Take the experience with Medicare, Medicaid and all other government health insurance programs.

If Medicare pays less than the doctor’s cost-of-staying-in-business (which it does), then the doctor CAN NOT (this is not a question of will not) accept a Medicare patient. If having Medicare insurance guarantees the doctor will not see you, then having government insurance guarantees that you will NOT GET CARE: the opposite of what was promised. Unfortunately, things are even worse than that.

Having any kind of insurance – government or private – may not guarantee getting care. Evidence shows a 20% fall-off in applications to U.S. medical schools. Forty percent of physicians in their prime are considering early retirement. There is hard evidence about our nursing shortage: over 500,000 positions are presently unfilled. So even if you had insurance and even if it paid well, you cannot get care if there are no nurses or doctors. Having insurance does not equal receiving care, and magical thinking will not make it so.

“HR 3590 will reduce errors and improve quality.” This is more magical thinking or worse, a WMDc (weapon of mass deception). To do either – reduce errors or improve quality – providers must learn. That means taking risks and easy access to lots of data, including bad outcomes. Evidence shows that the tort system, the security tightening of HR 3590, and FDA draconian regulations are killing healthcare’s ability to try new things and learn.

Magical thinking by children can harm them. Magical thinking by Washington can kill us. Those with power in Washington are not children, but they think like children, magically, and ignore the evidence.

We tolerate magical thinking by children: that is part of childhood.
Why do we tolerate such behavior in our ‘Representatives?’

System MD

Tweet This Post Buzz This Post Delicious Digg This Post Facebook Stumble This Post

There are several types of tapeworms (Cestoda) that infect humans. They latch on to the host’s intestinal wall and absorb nutrients that are supposed to feed the host. Tapeworms survive and thrive at the expense of their host. Typically, they release their hold, fall off the intestinal wall and are excreted before the host dies of starvation.

Healthcare has a tapeworm but it won’t let go. It keeps growing as the host consumes more but gets less nourishment. The worm’s full technical name is Bureaucrator defensis uber alles (BDUA) or bureaucracy for short. Because it won’t let go, the host called Healthcare is starving to death.

According to Darwin (“On the Origin of Species,” 1859), biological organisms survive in order to procreate. BDUA is different. It survives and defends itself solely for the purpose of expanding or enlarging and does so at the expense of everything, including its host.

Host healthcare is gorging itself…on money. The U.S. consumes more healthcare dollars per capita than any other nation. Since money is the energy source by which systems do whatever they do, one expects that the system that uses the most energy (consumes the most money) gets the most benefit. Not so!

The U.S. spends more of its gross domestic product on healthcare than Canada (50% more in USA), Japan (48%), United Kingdom (46%), Germany (35%) and Switzerland (24%). The U.S. ranks behind every one of them in how long we live and infant mortality.

To paraphrase a beer commercial, we are spending more and getting less. Plagiarizing Peter, Paul & Mary, “Where has all the money gone?” Answer: the “waste of the middle,” consumed by BDUA. Roughly 40% of all the dollars that go in to the U.S. healthcare system never come out. When you are talking about $2.5 trillion, even Senator (deceased) Everett Dirkson would call $1 trillion [40% of 2.5 trillion] some “real money.”

Imagine what the nurses and doctors could do for us if they had a $1 trillion more than what is available now!

There is one huge difference between BDUA and the more common human tapeworms (Cestoda). When an individual human is infected with Cestoda, the person cannot decide what the tapeworm eats versus what goes to the host.

For BDUA, we can say how much [money] goes to it and how much goes to us [patients]. By requiring cost/benefit analysis for all food [money] going to the bureaucracy (BDUA), we can reduce its obscene, life-threatening eating habits and have more health care for people.

I often repeat Dennis Miller’s famous closing line, “That’s just my opinion. I could be wrong.” Not this time – I know I am right. In a choice between our welfare and the tapeworm, we must choose us.

System MD

Tweet This Post Buzz This Post Delicious Digg This Post Facebook Stumble This Post

As Americans, we are all guilty of imitating the ostrich. We hide our heads in the sand to avoid confronting painful, difficult questions like: Do we want to have capitalism in healthcare?

“Capitalism” above refers to the free market, financial incentives, money as reward.

DO WE WANT FINANCIAL INCENTIVES IN HEALTHCARE?
If the answer is no, then we solve healthcare problems using a centrally controlled, government regulated system unaffected by capitalism and market forces.
If the answer is yes, should financial incentives govern ALL goods & services? If financial incentives apply only to some parts of healthcare, which ones should be market-driven and which ones should be entitlements?

As long as the Public ignores this crucial question, our healthcare system will continue to be structured according to the ideology of whichever Party is in power, focusing solely on their immediate political advantage and NOT on our long-term welfare.

Why does capitalism fail in healthcare?
Capitalism–a free market that balances demand with supply–works by using money to connect consumer wants and needs (demand) with the production and distribution of goods and services (supply). We have cheaper and better computers because consumers forced the suppliers to compete. The same thing happened to Lasik eye surgery. The key is the connection between demander/consumer and the supplier/producer. In healthcare, supply and demand are disconnected.

For capitalism to function, the consumer must have control of spending and enough information to be a wise shopper in his or her own self-interest. In U.S. healthcare, the consumer/patient has virtually no control over who will provide service or what service will be provided. The consumer/patient who needs a hernia repair has none of the usual information available when buying a car or hiring a lawyer. The consumer/patient does not pay for what he or she is consuming, at least directly. Under these conditions, how can any patient be the rational consumer on which capitalism depends?

Contradictory incentives
HR 3590–Patient Protection and Affordable Health Care Act of 2010–makes our system even more confusing and contradictory than it was. Consider the insurance conundrum described below (that HR 3590 expands).

Another example of contradictory incentives can be found in HR 3590’s elimination of physician-owned investments. The theory is that when doctors own hospitals or test equipment, they will order unnecessary (and expensive) tests and procedures because doing MORE makes them more money. There is evidence to support this theory.

There is also evidence of the converse. When doctors are paid a fixed sum of money, they will defer doing necessary medical activities because in a managed care system NOT doing tests and procedures is how they make money.

Either way, financial incentives can encourage doctors to behave in ways that are counter to the patient’s welfare. Our present healthcare financing places the patient’s best medical interest in direct conflict with the physician’s best financial interest.

Insurance Industry
What does the medical insurance industry actually do? Underwriters calculate predicted risk and potential payouts. Private insurers maximize profits by spending as little as possible of their collected premiums. Government insurers also seek to spend as little as possible in order to stay within budget. “Spend as little as possible” translates to paying for the least care they can get away with.

The medical insurance industry suffers from the contradictory incentives built into our current healthcare system. Patients want their insurers to pay for whatever medical care they need or want. Shareholders want insurers to pay out as little as they can in order to maximize profits. Taxpayers want government insurers to pay out as little as possible to avoid tax increases. Incentives discourage providing care.

U.S. Pharmaceutical Industry
Using any metric you like–number of patents, drugs in use, volume of research–the USA creates more and better pharmaceuticals and medical devices than the entire rest of the world put together. Why is that? Answer: the U.S. has a powerful financial incentive system that encourages such development.

Try a simple calculation. Flomax is a drug that relieves obstruction to urination in men caused by an enlarged prostate gland. Say Flomax costs $1/pill and you take one per day (=$365/year). Say Flomax prevents the need for surgery on your prostate (estimated cost ?$20,000). It would take 54 years of Flomax to equal the cost of one operation, without even considering the risks, discomfort, and loss of productivity associated with surgery. Which is better? Do you still think $1/pill is exorbitant?

What about Lipitor at $2/pill if it staves off $100,000 heart surgery? The answers come from long term cost/benefit analysis but no one does this calculation. Currently the only, and I do mean only, factor considered is immediate cost. No one talks about cost/benefit.

Should We Have Financial Incentives in Healthcare?
What matters when answering this question is our collective decision and not Congressional wisdom, Presidential politics, or some expert’s branded solution. The Public needs to discuss financial incentives openly, come to some consensus, and transmit that consensus to the Federal government. Without that, the contradictory mess we currently have will persist.

There is in our country a “consensus of futility.” They believe that money-in-healthcare is too volatile, polarizing and fundamental for us ever to achieve a general consensus. I disagree and counter with civil rights. THAT was violently vitriolic, inciting riots and killings, yet we now have a general (not universal but getting there) consensus that people are people regardless of the color of their skin, religion or place of origin. If we can do that, we surely can come to some agreement about dollar flow in healthcare.

WHO should pay and for WHAT?
After the Public decides on incentive-based or flat rate payment, there remain two key questions. WHO should pay? WHAT should they pay for? Spending on healthcare should not be viewed as a simple cost item, money down the toilet. It is or should be an investment in our futures, both as individuals and as a nation. Investments should: a) have a positive cost/benefit ratio, and b) be paid for by those who benefit.

When people are healthy, both the individuals and the country as a whole benefit. WHO should pay? Answer: those who benefit–both individual and nation. What should they pay FOR? Answer: they should pay for those outcomes or results with positive long-term cost/benefit ratios: access and service, good medical outcomes, sustained health and productivity, longevity, as well as rules, regulations and laws that are worth what they cost.

If we can get those things using fixed payments, great! If we need incentives to get quicker access, better service, new drugs, longer lives, then we should use incentives–the free market–to get what we want and need.

System MD

Tweet This Post Buzz This Post Delicious Digg This Post Facebook Stumble This Post

Those who advocate repeal of the self-styled Healthcare Reform Act–HR 3590–have been labeled as unfeeling, loony, anti-democratic, anti-Democratic [party], Those-who-only-know-No, and anarchists. The correct epithet is good Americans.

Repealers are American.
In contrast to the President’s exhortation to listen more attentively, Americans HAVE listened and more important, we have watched what Congress has done. Regardless of what demagogues claim, Repeal is not based on party affiliation. Democrats and Republicans alike understand that this is bad legislation, will make healthcare sicker, and put our nation deeper into a financial hole.

The partisan charge over this issue crystallizes a key problem: it polarizes a national, not a political party, concern. Fixing healthcare is not and cannot be a Party achievement. We must FIRST have national consensus and then build the fix–a new system–on that American consensus, not based on a Democratic or Republican platform or political compromise.

Eleven States in our Union are exploring a reversal process. Polls show that over half of our citizenry actively oppose self-styled Healthcare ‘Reform’ and the rest are doubtful it will work. Why are people rejecting what we are told will fix healthcare?

Repealers DO care.
The President promised that HR 3590 would expand service adding, “if you like your doctor, you can keep him [or her].” As part of the final ‘Reform’ package, the Senate voted to cut Medicare reimbursements by 21%. Cutting reimbursements has an iimmediate, direct effect: it reduces availability of doctors to see patients. As Medicare reimbursements are cut even further, physicians will be unable to afford to accept Medicare patients and still keep their offices open.

HR 3590 dramatically increases the size of bureaucracy while simultaneously reducing the availability of providers. Repeal would do the opposite. Which group–bureaucrats or doctors–delivers care to patients? Now, ask yourself who cares about patients?

Repealers understand inconsistency.
The President started his push to reform’ healthcare claiming (rightly) that, “The system is broken.” HR 3590 does nothing to fix the system. In fact, it makes the system sicker: unsupportably expensive; more regulated and therefore less able to learn; while reducing availability of care. The Act is exacerbation, the opposite of reform.

If what you are doing is making things worse, don’t you stop?
Repeal is the sane, logical and appropriate response to HR 3590.

System MD

Tweet This Post Buzz This Post Delicious Digg This Post Facebook Stumble This Post

I write the following with great frustration. If we do not accept some level of personal responsibility for our own health, our health care system can never be fixed.

Today’s diatribe was stimulated by an event that happens every day to every U.S. doctor.

Case
One month ago, a seven year-old child was seen for a possible rhtyhm problem of the heart. The child was eligible for Medicaid but the mother had not applied. Considered urgent, I saw the child and did preliminary tests but could not bill anyone because there was no funding source. An exercise stress test was scheduled for the following month. Mother promised to apply for Medicaid in advance.

Yesterday was the day for the stress test. The family failed to keep their appointment. When our office contacted the home, mother responded that the child was sick with strep. She wanted to reschedule the stress test for when the child was well. Mother still had not applied for Medicaid.

Last week mother took the child to the pediatrician. Because the child was sick the pediatrician evaluated the child while knowing this would be ‘free’ care because mother refused to fill out the Medicaid application forms.

WHY IS THIS OKAY?
A-B-C-D below happens every day in thousands of variations across our country. Neither doctor nor hospital can “Just Say No,” both for moral as well as legal reasons.
A) The patient gets care.
B) The family pays nothing.
C) Without a funding source, the doctor and hospital are not paid.
D) Doctor and hospital must still pay their fixed costs.

Personally, I believe such rejection of personal responsibility is corollary of the belief that health care is a right. Whatever the reason, I ask again, why is this okay? What if everyone behaved like my patient’s mother?

Imagine a scenario where affordable health insurance is universally available such as promised by H.R. 3590 (PPAHCA). Suppose that someone chooses not to enroll. That person goes to a doctor because of a heart murmur. Should the doctor see the patient?

If you believe that the doctor should care for the above patient regardless, then there is no such thing as personal responsibility in healthcare.

What about other countries?
In universal health care countries, you must be “on the list” to get care. This means if you are a citizen, you will be enrolled in the government system: you cannot decline. In countries without universal health care, you must have private insurance or pay up front to get medical care. Without one of those two, you do not get care.

System MD

Tweet This Post Buzz This Post Delicious Digg This Post Facebook Stumble This Post