Health Medicine Update

Archive for the ‘topical debates’ Category

It was never about Health.  It was never about universal health care.   Access does not equal care and certainly not quality care.   Yes, one side “won.”   This is not a victory for you.

It is not a left-wing agenda.  It is not socialized medicine.  This is the first time the Federal Government has mandated the purchase of a private party product.  And from the very racketeering group that is the root cause of the problem in the first place.   What a travesty.   Another government subsidy.   Effectively amounts to another “government bailout.”

As Michael Moore wryly said:

The larger picture here is that the private insurance companies are still the ones in charge. They’re still going to call the shots. And if anything, they’ve just been given another big handout by the government by guaranteeing customers. I mean, this is really kind of crazy when you think about it.

This is not the same as a state mandate for auto insurance.

The State of California is unrelenting on this point.  Driving is a privilege!  It is not a right.  If you do not drive, you are not mandated to purchase auto insurance.  Furthermore, the reality is auto insurance does not cost $5000-12,000 annually.

This is the first major landmark piece of legislation in American history that was passed by such a narrow margin without a single Republican vote.   Social Security passed with bipartisan support in 1935 — 81 Republican Congressman and 16 Republican Senators.   In 1965  Medicare passed with bipartisan support –  70 House Republicans and 13 Senate Republicans.  In 2010 there was not one single Republican vote.   And the margin in the House was razor thin — 220 to 212.

It also violates a well-tested political strategy — sell it first to the American people who will then pressure Congress to pass new legislation.  The public is not aboard.   The latest Quinnipiac and Washington Post polls show the public still opposes this landmark Act.

AT&T has already made plans for a $1 billion write-off in advance of cost shifting.   And legal staff is hard at work looking for technical loopholes.  This just in from Robert Peer at the New York Times:

William G. Schiffbauer, a lawyer whose clients include employers and insurance companies, said: “The fine print differs from the larger political message.  If a company sells insurance, it will have to cover pre-existing conditions for children covered by the policy. But it does not have to sell to somebody with a pre-existing condition. And the insurer could increase premiums to cover the additional cost.”

Everyone is giddy about “the win.”   This is only the end of the beginning.

Remember the Telecommunications act of 1996?   It was enacted to guarantee local competition amongst the major carriers.  It never happened.

Now watch this interview with Michael Moore:

My take on why we saw the thrilla in … Massachusetts:

From Inside Washington, Nina Totenberg encapsulated it best.   The economy and job prospects dwarf all other issues.

If we had 5 percent unemployment, he probably would have gotten the plan through.  But you can’t refocus people’s attention on an aspirational goal for a society — I think it’s very difficult to do that — when people are hurting so much in the immediate sense and businesses are going down the tubes, small business on a daily basis.  You just look in any mall, places you’ve gone for years, they’re gone now.  People in every level of life are struggling to even have a job or they’re working part time.  Kids coming out of school can’t find jobs.  This is a very dire situation and he has – I can’t say he’s ignored it, but he hasn’t focused on it in a way he probably should have.

From the Chris Matthews Show, David Brooks always seems to have to most cogent social insights:

Mr. BROOKS: Yeah, if I had to generalize, it used to be in this country people of high school degrees lived the same kind of lives as people with college degrees. That’s no longer true. Divorce rates, attitudes towards society, attitudes towards government, it’s very different. College degree, non college degree.  …  And they look at the people who are running them, most of them are college degrees, Harvard law, on both sides.   …  And they say, `That’s not me. That’s not my life.’   …  `And they’re not listening to me.’

And so the President shifts focus in his annual State of the Union address.  It’s about jobs and the economy.  Then education … our future.

Where is this train wreck headed?  Wending its way through the various Senate and House subcommittees, the health care reform debate of 2009 is approaching a crescendo.    What do we have to show?   The question I posed in a previous post still has yet to be answered – just what is the problem?  Is the problem greater access?  Is the problem escalating insurance premiums?  Is the problem stratospheric and ruinous hospitalization bills?  Is the problem rapidly declining quality of care?  Or is this simply become a matter of whose team wins?  The bill fails — the president sinks.

Andrew Weil concludes:

But what’s missing, tragically, is a diagnosis of the real, far more fundamental problem, which is that what’s even worse than its stratospheric cost is the fact that American health care doesn’t fulfill its prime directive — it does not help people become or stay healthy.

Read the rest of this entry »

What is the message?    What do you want?

The World Health Organization definition of health has not changed since 1949.  We were asked this the first day of medical school.  No one answered correctly:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Political strategists play with focus groups to achieve Machiavellian goals.  Issues can be framed positively or negatively.  In a recent series of  soundbites with Republican and Democratic response tracks, Republican strategist, Frank Luntz,  found the political segment that was most effective for both Republican and Democratic viewers was the one that featured a female physician.  She was real, conveying substance and legitimacy.   See Luntz explanation of focus and metaphors.  For an even more revealing look at looking at mind-control watch  The persuaders — one of the most eerie documentaries FrontLine ever produced.

This week the President met with “selected physicians” to shore up his support.

This entire public debate would have had been far more successful with tighter focus and goals — health insurance reform and regulation.  We may be on the verge of another government giveaway.

John Podesta,  President Clinton’s Chief of Staff, was interviewed on the Charlie Rose show last month.  His words were quite prescient.

“We’re very close to finally doing what for 60 years presidents and congresses have been trying to do which is to produce quality, affordable health coverage for every American.”

And therein lies the killer paradox.   Affordability implies universal access.   Universal access implies quantity.   Quality and quantity are mutually exclusive.  You don’t go to Costco or Target or Wal-Mart for quality service.  If you’re lucky, you may find quality merchandise.  But not service.

Health maintenance organizations (HMOs) were heavily promoted by the Nixon administration in 1973 to contain costs — Managed Care.  We physicians had another name for it — “mangled care.”   The largest of all HMO’s today, Kaiser Permanente, demands minimalist, algorithm-based, cost-driven medicine.  Lonnie Bristow, a former President of the AMA, recently called this “a work in progress” at a town hall meeting here in Northern California.  Indeed, a work in progress.

Want to know the simple formula for HMO Medicine?   And by extension the cost-savings approach to medicine?  It is a very simple formula.

Lives x Capitation = Revenue

That’s it.   It’s all a numbers game.  Notice what drops out?   Quality!   Not even factored into the equation.   Using a simple mathematical model you can see that cost-driven medicine (managed-care)  is incompatible with quality of care.  And that is what we all experienced, those of us who have practiced in HMOs in the past.  All of us.

The administration and congress is using the same old arguments proffered over 30 years ago.   We will be saved by the cost-cutting gods.  The Green Visor man.  The guy that eventually wraps up every car deal.   Read Dr. Bernadine Healy.   Then from Kip Sullivan of Labor Notes:

Biemiller went on to say that HMOs ‘can provide better quality medical care at lower cost than the fragmented fee-for-service system’ and that the savings HMOs could achieve were ‘enormous.’  His only significant reservation about Nixon’s HMO bill was that it would have subsidized for-profit HMOs.  But because there is no evidence that managed care is less toxic in the hands of nonprofit than for-profit HMOs, this reservation was of little significance.

Harvard and Stanford trained Dr. Margaret Hansen aired this short segment on KQED radio — the lost art of medicine.   Ancient voices from Andalusian Spain, Maimonides, echo similar sentiments every bit as fresh today as when written in the 12th century.

Medical practice is not knitting and weaving and the labor of the hands, but it must be inspired with the sole filled with understanding and equipped with the gift of keen observation; these together with accurate scientific knowledge are the indispensable requisites for proficient medical practice

The ancient wisdom of the Greeks was lost to Western civilization for 1000 years after the fall of the Roman Empire that had succumbed to endless corruption, incompetence and sybaritic excesses.  Greek culture and knowledge passed to Byzantium and Islam.   I appear as either a dinosaur/curmudgeon like Paul Muni in the Last Angry Man or a messenger from the future.  We were taught the “laying on of the hands” was essential to diagnosis and healing.   Great medicine is the accomplished art, intuition and inductive logic of the physician with the wise use of modern technology. Attributes of the 15th Century Surgeon should still be emulated: the eye of an eagle, the heart of a lion and the hands of a woman, the gentleness of a lamb and the patience of a saint.

Service, expertise and time.   That is the challenge.   Will you receive necessary and deserved time, expertise and personal service or simply a 10 minute expedient and tangential encounter? Is this the face of medicine?

Robotized Doctors

The new medicine awaits — like the Phoenix rising — the paradigm shift.

Post-war Britain, and Londoners in particular, had suffered mightily after two years of punishing aerial bombardment.  The East End of London had been reduced to rubble.

Winston Churchill, arguably the greatest leader and politician of the 20th century, was turned out of office.  A new day dawned.  Anuerin Nye Bevin, a “firebrand” Socialist, was determined to remake the British health care system.  On July 5, 1948 he became the first Minister of Health.   Out of his uncompromising efforts was born the National Health System.  Bevin became known as the father of the NHS.  The pride and joy of Britain today.   Out of crisis comes opportunity.   And so it is today.   With crisis, opportunity comes aknocking.

Read the rest of this entry »

Joseph Campbell first offered this sage aphorism:

“If you want to change the world, you have to change the metaphor.” - Joseph Campbell

The president subtly changed the metaphor this morning in a major financial address.  Instead of the phrase health care reform he used the phrase health insurance reform.  Ah , now we are framing the right debate. Was this metaphorical or strategic?

We have argued for months now that this is not about health care reform.  Want real health care reform — you change the paradigm.  Read Deepak Chopra’s OpEd this morning in SFGate. Then read all our past and future posts.  The advent of the 21st century is quickly evolving.  Old paradigms, companies, and entire industries are vanishing.

The current debate is about economic reform.  And economic reform is about insurance reform — catastrophic economic reform.

If health care is central and vital to the health and well-being of the nation, then health insurance should be regulated as a utility.   As if Dr. Howard Dean had been following our very advice, just yesterday on Meet the Press, he offered the same prescription:

There’s another way.  There’s two countries in Europe that have universal health care without–and it’s entirely run by insurance companies.  But they treat the insurance companies like regulated utilities.  If the insurance companies would prefer to be treated like regulated utilities, we’d drop the public option in a heartbeat.

– Howard Dean

This graphic from the morning’s news even better.  Shows that the administration may be serious about the fundamentals of a healthy economy first.

financial reform first

And now we wait for the speech of a lifetime.  The make or break — defining speech.  We wish this unreal set of expectations on no one.

Medicare for all?

Let me renew this debate with trilogy of  blogs over the next week.    First with a set of charts and diagrams laying the foundation for the daunting statistics that face us.

First consider this simple chart plotting the inexorable rise in yearly total health care expenditures from 1960 to 2016  (estimated).  There is barely a perceptible sag at about 1995 .   To imagine an external force (the government) having any measurable effect on this curve stretches the imagination.

National health care expenditures Statistical Abstract of the US

Read the rest of this entry »

Steroids.

What was the first thing that came to your mind?  A particular sport?  Another notable sports hero?

We live in a world of code.  Single words evoke powerful images and thoughts.  You have been programmed.

Steroids. Corticosteroids? Mineralocorticoids? Anabolic steroids?

Performance-enhancing drugs.  Another powerful image — right? One more loaded term.

Read the rest of this entry »