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Archive for the ‘Medical Politics’ Category

PostHeaderIcon Health Care: The Day After

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:

PostHeaderIcon Health Care Reform: Myths and Misunderstandings

Too often have I written about the endgame.  Shades of Mark Twain — reports of my death are exaggerated.  But this really is the ninth inning.  The problem is the president is looking for the long ball — the out of the park home run.  When he should have been hitting singles, or emulating the great Joe Montana — short yardage high percentage gains — not Hail Mary passes.

Ave, Imperator, morituri te salutant

The secret fate of all voting democratic House members.  The arm twisting in the house rises to epic proportions not seen since the days of the infamous Tom DeLay – the Hammer.

This will be a bad bill.  You are all unwitting pawns in this game.  It will solve nothing.  It cures nothing.  It has emboldened the insurance racketeers and Big Pharma.  It has only one potential good outcome — Rush Limbaugh has promised he will leave the country.

They have rolled Howard Dean and Dennis Kucinich.   Other voices have been marginalized – Bernadine Healy, Robert Reich, Norman Goldman of Talk Left, Marcia Angell. And who will benefit from a fatally flawed passage?   The rising unaffiliated — the independent vote.  This is a Greek tragedy.   A Pyrrhic victory.

We are all too aware of the right wing echo chamber.  A well orchestrated score promoting stereotyped rat a tat answers.   How do they do this?

The same may be true in on the left as well.  We hear platitudes and assertions over and over again without challenge.

1. United States ranks number 37 in the world in healthcare.

Why repeat this assertion over and over and over again?  Because it makes a false point.

This figure is derived from life expectancy in the OECD  (organization of economic cooperation and development) countries.  The spread is narrow – less than five years.

My friend Burton Goldberg, one of the most successful publishers of alternative medicine, constantly beseeched me on this issue — investigate life expectancy derivations.  Life expectancy is a highly complex mathematical formula that balances death with infant mortality.

A country with a high infant mortality has a lower life expectancy rate – at birth.

For the most perplexing reasons, the United States still has a relatively high infant mortality rate.  If the figures are adjusted for life expectancy after the age of 60 we rate number 5 in the world.   If life expectancy figures are adjusted after the age of 80 we rate number 3 in the world.

In other words, as we advance in age, the effect of infant mortality is factored out and the real life expectancy becomes more apparent.  We are not number 37 in the world.  We are in the top three.  Life expectancy figures beg a revised definition.

Life expectancy change with age

US Life Expectancy -- 3rd place by age 80

Furthermore, life expectancy is a dreadfully  inadequate measure of the health of a nation.  It says nothing about the quality of life.  HDI, (Human Development Index) may be a better measure.]  It says nothing about vibrancy, activity, mental health, social health, sexual health, or productivity.   It simply means that you crossed the finish line at a particular age.   No matter whether you dashed across or fell across the finish line and died.

In Anti-Aging Medicine, we talk about “squaring the curve.”  Increased Health Span and not Life Span.  A healthy life until old age followed by sudden death.  Not a slow inexorable painful march to the end.

2. The medical system suffers from over utilization.

Not as I see it.   Quite the opposite.  I see scores of patients who have pleaded for years for adequate and thorough lab testing only to needlessly suffer through unnecessary dysfunctional states   This is a natural consequence of HMO and PPO medicine.   Bottom-line cost-recovery medicine is a zero sum game.

3.  If you do not pass this bill everybody will end up in the emergency room.

There is such an appalling lack of medical input in this entire debate.   Urgent care medicine had its roots in the 1980s.   Originally funded and promulgated by astute entrepreneurs and ex-emergency physicians, these facilities answered the need for acute medicine outside of an emergency facility.   There are more than 8700 Urgent centers visits vs. 4600 emergency departments.     [And by the way, Emergency care represents less than 3 percent of the nation’s $2.1 trillion in health care expenditures while covering 120 million people a year.]

This is market-oriented medicine.  A workable and elegant solution in response to a market demand for immediate care outside of exorbitant emergency rooms.   They are successful and see all comers.   In Atlanta alone, my good friend Jordan Rice, one of the leading Urgent Care entrepreneurs in the country boasts of the ability to see any and all comers — Medicaid and cash paying patients.

Even the original Medicare bill of a 1965 garnered 13 Republican votes in the Senate and 70 Republican votes in the House.  To pull every legislative trick in the book only underscores the thinness of support for this ill-conceived rewrite of our society.  To be honest, Michelle Obama’s anti-obesity campaign could have more far-reaching effects that all 2700+ pages of this legislative lunacy.

PostHeaderIcon Health Care Reform: a Postmortem Requiem

Last night health care reform died.   What went wrong?   A plethora of explanations from all the usual suspects to follow.   You will hear some rumblings of dissent — press on.

The simple answer:  everything was wrong.   This never was about health care reform.  This was always an attempt at health insurance reform.  And in that regard it was a miserable failure.  The bill, as passed by the Senate, was a cruel proposition.  The ultimate lay away plan: pay me now and you might be able to enjoy your coerced purchase in four years.  Do you know how much can change in four years?  Everything.

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PostHeaderIcon Healthcare: a Christmas Present of Epic Proportions

Half a loaf?  No, worse.  Here is your pre-Christmas present — a big lump of coal.   Let me simplify and make clear my assertion.  You are ill, in need of medical care.   You want the best.   Whose wise counsel and help do you seek?   You want someone who is sympathetic, skilled and competent.

Dr. Howard Dean

Political HealthCare

This debate has never been about Health.   Certainly not your health.  For the last six months I have steadfastly maintained the large insurance racketeers will not lose this one.   They have thrown all their money into the ring.  It has paid off handsomely. Their paid surrogates have performed well.  Like their Wall Street kin, the pirates have won again.   Robert Reich pulls no punches:

In other words, the private insurers are winning and the public is losing.

Pharmaceutical companies are winning as well.

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PostHeaderIcon Keith Olbermann Sounds the Death Knell

Keith Olbermann, always impassioned, penetrating and reflective. The chorus rises: this bill with it’s mandated participation in the insurance protection scheme cannot be supported.

A bad and corrupt bill is worse than no bill at all. The President’s high stakes gamble is overtaken by the raging storm of job insecurity and … the economy.

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PostHeaderIcon Howard Dean Says It’s Time to Kill This Bill

Howard Dean at his most articulate and unambiguous self.   The time has finally come.    There is nothing left to support.   It’s now face saving time.   It is not about Joe Lieberman.   He’s just become the Mannie Ramirez of the Senate.

“It’s not health care reform … and it’s too bad it’s come this.”

“You are going to be forced to pay, on average, 27% of your money to pay CEOs $20 million a year…”

[starts at about 4:08 into this clip]

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PostHeaderIcon HealthCare Napkins: It’s Not About HealthCare

Single payor is not the answer.   But this is an illuminating sketch of “HealthCare 101” coming into the bottom of the 8th inning.   What is missing is the critical distinction between big business vs small business in medicine.   Your old fashioned GP was in small business much as he/she always protested to the contrary.

PostHeaderIcon Trying to Please Everyone and No One – part 2

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.

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PostHeaderIcon Trying to Put Genie Back in the Bottle

We have seen the emergence of “evidence-based medicine” in the last 10 years.  This has been an effort to further legitimize and give scientific basis to common medical therapies.  A medical version of “show me the money.”  I have always thought this was rather inane, since it presumed that all medicine for the last 2000 years has been unscientific and irrational.  Although the reality is medicine is not nearly as scientific as asserted.  Only 10-20% of medical practice is based on sound scientific principles.   This rankles most physicians who believe that conventional medicine is scientifically-based.  The highest form of medicine is the practiced art using scientific principles and technology.

A series of US Task Force recommendations are being rolled out by the Department of Health and Human Services.  These are well-intentioned and rational.  Examining the literature and epidemiology of medical practices in an effort to determine what is safe, sane, practical and effective.   The trap is “effective” as you will see.

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PostHeaderIcon Healthcare Focus: Quality or Quantity

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

Robotized Doctors

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