Health Care For All Americans

In the 12/18/2008 New England Journal of Medicine, Robert Steinbrook, M.D., asks "Medical Student Debt - Is There a Limit"? Steinbrook reports that 87% of the students graduating from medical school in 2008 were encumbered by debt, $145,000 for students at public medical schools and $180,000 at private medical schools. He reports median costs of attending medical schools ranging from about $44,000 for public schools and $62,000 for private schools. He reports that 20% of the financial assistance of $2.5 billion provided in 2006-07 were grants and scholarships; the remainder was mostly loans.

The financial burden of a medical education eliminates worthy students who cannot accept the yoke of personal indebtedness, the spectre of burdening their families with escalating debt, or the unlikelihood that a school loan can be arranged under reasonable repayment terms. In the last year, disclosure of the corrupt association between some institutions' financial aid officers and student loan companies makes it clear that this program does not serve our public interest.

Students who graduate with enormous debts focus on specialties which generate enhanced earning power, not necessarily specialties which are most needed by society. Students who graduate with enormous debts will practice in a manner which enhances income, constrained only by insurance company and government rules as well as state/federal fraud and abuse laws. Many of these students may feel that they need to focus more on the business aspects of their medical practices than the professional aspects.

I end the year by again proposing a federally subsidized program for medical (and other needed health professional) education. Students receive appropriate financial support in exchange for an extended service commitment which begins after completion of training in fields which are needed for our health system. We develop a corps of physicians and other health care providers who agree, in exchange for their financial support, to serve in federal health centers which compete with private health systems in a national program which provides adequate and appropriate health care to every citizen.

Let's just do it!

Happy New Year - may it be a year of peace, happiness, prosperity and good health to each of you.

FDR: It All Depends On Whose Child Has The Measles

This evening, as my wife and I visited a local Kaiser Foundation Hospital, the air stank from wood smoke. I found myself surprised that Kaiser hasn't taken steps to discourage wood burning in fireplaces in the Silicon Valley.

In earlier posts, I talked about "cost-shifting." That occurs when an insurer, or the government, or a medical facility saves money by shifting the cost of services to someone else, usually another institution or even the patient. It seems unfair, doesn't it? If it impacts us, it doesn't just seem unfair, we complain loudly that it is unfair.

The reason I introduced this blog with the stench of wood smoke is that it exemplifies an unrecognized cost-shift component of our health system. The people burning paper, debris or wood in their fireplaces shift the cost of being warm from themselves to the public. If someone has asthma and decides to open a window, or even worse, take a walk in the brisk polluted evening air, those fireplace fumes can trigger an unexpected very expensive emergency trip to the hospital with an acute - potentially fatal - asthma attack. Smoke up the fireplace triggers asthma which requires substantial costly resources to treat.

Not all cost shifting is done by insurers, government agencies, hospitals or health care providers. Some of it is done by people who, in the mirror, look just like us. But of course, when it's our pocketbook which is at risk, we convince ourselves that it is OK, just as when it's our measles unvaccinated child who spreads his infection to another susceptible child, it's OK too.

Will The Last Doctor Turn Off the Light When Leaving?

In 1971, at a Los Angeles Practicing Law Institute program devoted to "health law", an academic speaker talked about the passivity of physicians with respect to the Medicare program. He told us that chiropractor and podiatrist organizations lobbied aggressively to have their members participate in the Medicare program, with fee schedules which were beneficial to them, while physicians and their organizations took a disengaged stand.

I have never understood the passivity then (and now) shown by physicians (the AMA was actively involved in trying to scuttle the initial Medicare legislation, predicting accurately, that the financial justification for the program was far off base), nor the political and business passivity shown by physicians as HMOs, PPOs and insurers played a variety of hard-nosed games which not only cut appropriate services to the public and their patients, changed medical practice to a factory/industrial model. and absorbed billions of dollars of "administrative overhead."

As more physicians work in groups run by lay management, are owned by hospital and other entities in which physician opinions are not particularly respected, and as business economics trumps professional judgment and standards, physicians continue to passively accept what has been meted to them. County medical societies and national physicians have chosen to spend time, energy and resources in fighting about which specialty gets the most beneficial treatment, rather than the state of the profession and the care which physicians and others in health care provide.

At one time, university medical centers provided leadership. But their lay managements have been accepting of the same strictures as physician organizations and have proved to be more concerned about generating profitable patentable ideas and products and selling revenue enhancing services then developing solid high quality systems of health care. Academic faculty missions have been subverted; teaching is less respected than publishing and generating institutional financial return.

Hospitals follow the industrial model. Just as skilled factory mechanics have been promoted to high-paying foreman jobs, promising young physicians are selected for a variety of directorships which gives them the choice of complaining and losing personal income and stature or keeping their mouths shut and not rocking their boats. Dissenting physicians may be labelled as uncooperative and, in a subversion of the medical disciplinary system, gotten rid-of.

We should not plan a return to the "good old days" when we watched patients die from infections, heart disease, cancer, obstetrical complications, metabolic disease and organ failure. But it's time for those who are in the health care trenches every day to speak up: health care decisions cannot be left to politicians, business people and economists. The lights are dimming now.

Ah Yes - Money

Tucked-away on pages A19 and 20 of the NY Times 12/19/2008 is this header:"Budget Office Sees Hurdles In Financing Health Plans," nicely packaged on a page which reports that the "good times" are no longer rolling in Louisiana and that a New Hampshire jury issued the first death sentence in "nearly half a century."

The only good news from the summarized Congressional Budget Office report was the use of computerized medical records would save the government a total of $34 billion over 10 years. Unfortunately, Robert Pear, the article's author, did not report the billions in total capital costs shifted by the government to the private sector to install and use those computerized medical record systems. Pear did report that $47 billion of new federal revenue would flow from requiring employers (those American businesses in competition with businesses in countries that do not have similar requirements) to provide health insurance or pay a fee to the federal government, that a national insurance pool for the uninsurable would cost $16 billion, that $116 billion could be saved by the government if it received a 15% discount from drug manufacturers for Medicare Part D drugs, that drug effectiveness research would save a puny $1.3 billion over 10 years as compared with $12 billion for implementation of generic versions of (presumably patented) "expensive biotechnology drugs." Pear also noted that the proposed 2010 and subsequent cut of doctors' fees, if not implemented, will cost the government about $320 billion over the next 10 years.

President-elect Obama won his election on a promise of change and improvement in health care quality, cost and access, but so far we haven't seen meaningful changes in his health policy and financing statements. Maybe we will - but more likely, we won't. The demands of the pinstripe-suited financial sector, the high-flying domestic automobile industry, the crumbling real estate industry and the health insurance industry seem to have come first.

Electronic Health Information Privacy - Office of Civil Rights

I received the following announcement today, which may be of interest to some readers:


"New OCR Guidance on the HIPAA Privacy Rule and the Electronic Exchange of Health Information


"The Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has published new HIPAA Privacy Rule guidance as part of the Department’s Privacy and Security Toolkit to implement The Nationwide Privacy and Security Framework for Electronic Exchange of Individually Identifiable Health Information (Privacy and Security Framework). The Privacy and Security Framework and Toolkit is designed to establish privacy and security principles for health care stakeholders engaged in the electronic exchange of health information and includes tangible tools to facilitate implementation of these principles. The new HIPAA Privacy Rule guidance in the Toolkit discusses how the Privacy Rule supports and can facilitate electronic health information exchange in a networked environment. In addition, the guidance includes documents that address electronic access by an individual to his or her protected health information and how the Privacy Rule may apply to and supports the use of Personal Health Records.


"These new HIPAA guidance documents are available on the OCR Privacy Rule Web Site at http://www.hhs.gov/ocr/hipaa/hit/. For more information on the Privacy and Security Framework and to view other documents in the Privacy and Security Toolkit, visit http://www.hhs.gov/healthit/privacy/framework.html."

Health Care Reform: Start With Educating Teachers

The seductive term, these days, is "health care reform." As with all seductions,there's a lot more going on than meets the eye. So let's look at the "reform" process from its beginning.

The first step in health care reform starts in our schools. Not medical schools, but the schools that train our kids' elementary and high school teachers' teachers. Before you conclude that my last sentence contained a "typo" read on. Once upon a time, elementary and high school teachers were trained in teachers' colleges by experts devoted to educating educators. Now, trainees attend community colleges and universities and take a smattering of courses in the liberal arts which give them no depth or real skill in any subject, and when they do get teaching jobs (some times choosing to teach as an afterthought), they bring no real teaching or deep academic subject skills to their classrooms. We need to improve the teaching and academic skill-sets of our elementary and high school teachers by providing intensive professional training by expert instructors in teaching and academic subjects.

Someone who does not love and have a firm understanding of math, algebra, calculus, biology, chemistry and physics cannot communicate a love for, or intellectual excitement about, these and other scientific subjects. Students decipher the real message: "I teach here because it's a way to make a living."

If teachers are not well-trained, skilled and committed, their students won't be either. And America won't turn out the "turned-on" mathematicians, physicists, biologists, chemists, physicians and other scientists it needs. We will churn-out minimally competent health care providers who want 9 to 5 jobs to make a "living."

America needs to pay close attention, not just to the end product of our science education process, but to its entirety. Begin health care reform with educational reform.

Failed Industries: the Opportunity Costs of Bail-Outs

We've heard a lot about saving jobs by providing financial CPR to the Big 3 auto manufacturers recently. I won't discuss American auto industries' management incompetence or even whether consumers' car purchases represent a national investment or merely a gigantic wasteful prepaid expense. But I do want to ask: what are the opportunity costs of sinking money into an old-technology industry which cannot manage itself?

I spent this past weekend in San Francisco at the 50th Annual meeting of the American Society of Hematology (ASH), immersed in basic science, current life-science research and development, and the ultimate application of exquisite scientific discipline and research to patient care. The atmosphere was vibrant; the weekend extraordinary. When I joined ASH in 1978 (I am now "emeritus"), it was an organization of about 1400 physicians, basic scientists and researchers. Now, it has a membership of 16,000 with more than 20,000 persons from around the world attending the annual meeting. The discoveries described at these meeting, and the cross-fertilization as experienced scientific researchers, trainees, physicians and other persons concerned with hematology learned from each other and interacted, will revolutionize medical care in coming decades. Hematology has moved from the "black box" era (when we gave drugs without really knowing how they worked), to understanding many of the basic mechanisms of cellular function and disease not just at the chromosomal or genetic level, but at the molecular level.

The money we use to prop up our moribund American auto industry's "yesterday's technology", will not be available to fund scientific medical research which will pay significant dividends, not only through prolongation of life, health and alleviation of suffering, but through financial return on investment. Those missing dollars will not help to keep America scientifically pre-eminent. Failure to fund life sciences research will inhibit new systems of effective patient care.

America should consider its opportunity costs when it commits resources to bail out failed industries. Let's support scientific research and medical technologies which give us a return on our investment, provide significant high-paying employment and opportunity, and harness the brain-power of our country, rather than boost horsepower under the hood.

Let's Not Be Stupid About Health Care Reform

In the mid-1990s, after presenting a talk about the HIV-Infected Health Care Worker at the Tenth World Congress on Medical Law, in Jerusalem, Israel, I met with three medical directors of what would have been Israeli equivalents of three large American HMOs. Each of these men were serious, committed, knowledgeable and depressed about the status of organized health care for which he had responsibility. In each case, the influences of poor lay business management, ethnicity mixed with religion and politics, and budgetary shortfalls created a wasteful system which met none of the reasonable standards to which these directors were committed. They said that the care their organizations provided was substandard.

There is a lesson from this experience. When I recently proposed a health system for all Americans with a single independent federal payer, I also proposed a federal health corps competing with traditional HMO and insurance health care systems because I understood that unless a new health care system had competitive safety valves, it would fail. Unless there is a single responsible "inspector general" for the quality and availability of care for all Americans covered by our health system, patients will suffer. Unless there is a real downside to providing unnecessarily expensive, inaccessible, inappropriately limited preventive care, diagnostic testing, therapy for illness and a full range of appropriate pharmaceutical (and other) products and services, mediocrity will prevail here, too. And unless we construct an ethical and moral framework for our health system, we will have not done our job.

Listen hard to President-elect Obama's health care plans. If they don't incorporate a consensus on American ethical and moral health care standards, the influences of poor business management, ethnicity mixed with religion and politics, and budgetary shortfalls will creat a wasteful system which does not meet our families' needs. We need change, not the old system in new clothes.

Worth Checking Out

For worthwhile information concerning health care costs, see:

http://www.nchc.org/facts/cost.shtml

What's Threatening Our Healthcare System?

No, it's not an epidemic or an earthquake or another hurricane Katrina. It's health care cost inflation, which in 2007 (the year before the US government really started to run the Treasury's money printing presses overtime at full speed) was about twice the general inflation rate. The Medicare population is a prime inflation victim, as its members observed when their Federal Medicare premium and private (i.e., AARP) Medigap premiums increases wiped out their Social Security inflation adjustments robbing resources from food, clothing, shelter and donut hole prescriptions.

The health care inflation rate, at 6.9% was double the general inflation rate; employers paid an increase of 6.1% for health insurance benefits with typical insurance family insurance premiums of about $12,000 per. Our bill for all health care products and services is heading towards 3 trillion dollars.

As our citizens, in increasing numbers, age and become ill, the cost of their care will be reflected in health care inflation. As new technologies, pharmaceuticals and advanced biologic products are introduced, their costs will be reflected in health care inflation. And as the numbers of those needing expensive new services increase, insurers and other intermediaries will elbow their way up to the trough to demand their share of resources as a reward for their roles in "managing" health care.

When resources are devoured by wasteful programs and unnecessary bureaucracies, food, mortgages, education, defense, transportation will be shortchanged. That will not be sustainable.

This Thanksgiving, let us be grateful for our country's world leadership, the affirmative role it plays in our lives, our ability to meaningfully participate in government, prosperity (for many), and the opportunities Americans enjoy to enjoy freedom of thought, action and religion. And let us resolve to provide appropriate health care to all Americans in a kind, humane, efficient system which alleviates pain and suffering and extends valuable life.

Something Was A Little Strange

Medical school hadn't officially started: we were being oriented with cheerleader speeches from faculty and a memorable talk the by the student body president who told it the way it was, ending with the thought that nowhere in the medical school catalog was there any statement that we would be treated fairly.

That afternoon, as we gathered quietly in an auditorium, the student to my left introduced himself as "Sam" (not his real name). And then, as inkblot patterns flashed on the white screen in rapid succession, he whispered an offer to help me with the inkblot interpretations because he had a lot of experience with inkblots. I ignored him.

A few weeks later we had become intense experienced students, soaking up new words, concepts and information. Neuroanatomy was difficult, the exam notorious, and each person's semester grade depended on correct identification of the brain structures in which our instructor had inserted small numbered pin-flags. But there was a problem - at the front of the line named "Sam." As he came to each test specimen, he systematically removed each flag, replacing it within an inch of its original site. Bedlam ensued. Somehow, Sam escaped without being physically assaulted.

A week later, "Sam" didn't show up for class. The next day we learned that he had murdered his mother-in-law. The details were supplied by a national magazine a few days later. The informal consensus was that at least no-one would move the little numbered exam identification flag

HIV and Male Healthcare Workers

At New York's Downstate Medical School, one of the pathology professors delighted in asking students what US persons were (in recent times) most likely to die of smallpox. His answer, hospital laundry workers, was my introduction to health care workers as victims of work-transmitted diseases.

When researching my chapter concerning HIV infected health care workers in Clark, Boardman, Callaghan's "Health Law Practice Guide," I was puzzled by the lack of evidence of widespread transmission of HIV to health care workers. There were a few lawsuits by individuals who claimed to have contracted HIV infection during the course of their duties, but they were relatively uncommon and there were confounding factors: was the appearance of HIV transmitted from a patient, or the result of lifestype exposure?

As noted in Kaisernetwork.org Daily HIV/AIDS Report , the CDC has published a study in the American Journal of Industrial Medicine suggesting that male health care workers face a more than twofold risk of dying from HIV/AIDS related causes, as well as other bloodborne diseases (Hepatitis B and C). Female nurses were at lower risk of dying from HIV - related causes than women who did not work in health care.

So, we are back to the old questions: is it private personal lifestyle or decreased immunity or increased risk of work-related infection which accounts for these findings. Because there are confounding issues, such as workers' compensation insurance payments and employer liability payments which may be at play, it will take a large, well funded and staffed, and deep study to figure this one out.

Final Regulation to implement and enforce the Patient Safety and Quality Improvement Act of 2005

http://edocket.access.gpo.gov/2008/pdf/E8-27475.pdf

The final regulation to implement and enforce the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) has been published in the Federal Register today. In April 2006, Secretary Leavitt delegated to OCR the authority to implement and enforce the confidentiality protections of the Patient Safety Act in conjunction with the Agency for Healthcare Research and Quality (AHRQ), which is responsible for administration of the Patient Safety Organization (PSO) requirements. On February 12, of this year, AHRQ and OCR published the proposed regulation for public comment. On October 8, of this year, AHRQ and OCR published interim guidance to permit AHRQ to begin listing PSOs prior to the effective date of the final regulation. On January 19, 2009, the final regulation will be effective and supersede the interim guidance.



The final regulation establishes the procedures and requirements for the listing and operation of PSOs, as well as the privilege and confidentiality protection for patient safety work product. The final rule makes several modifications to the proposed rule, in particular adding new requirements for PSOs and clarifying how information is collected to allow efficiencies in provider operations when collecting similar information for different purposes.



OCR’s enforcement responsibility includes the imposition of a civil money penalty for a knowing or reckless impermissible disclosure of patient safety work product. A civil money penalty may be imposed in an amount up to $10,000 for each violation.



The Patient Safety Act recognizes certain provisions of the HIPAA Privacy Rule are implicated by covered entity providers seeking the protections of the Patient Safety Act. The preamble to the final regulation describes how the HIPAA Privacy Rule disclosure permissions operate in conjunction with the patient safety disclosure permissions.



You may review the final regulation in the Federal Register (http://edocket.access.gpo.gov/2008/pdf/E8-27475.pdf).

Was There A Free Lunch?

Early Monday morning, I had an office visit with a physician who had a "No Free Lunch" sign prominently posted next to the sliding glass reception window. The notice said that the doctor would not accept free lunch, samples, sales/educational information or other materials from pharmaceutical companies.

Two days later I attended a no-charge all-day continuing medical education program for approximately a thousand physicians, nurses and related professionals, conducted by a national medical education company which has been funded by pharmaceutical companies, an insurer and a local medical society. Subjects included incretin hormones for management of type 2 diabetes, osteoporosis prevention, reducing cardiovascular risk by focusing on HDL, the beneficial blood component, asthma, new Beta blockers for hypertension treatment, fibromyalgia and actinic keratoses/squamous skin cancer. These are all relevant medical subjects and just happen to be conditions for which medications may be prescribed.

While several pharmaceutical companies had tables with representatives, the number was smaller than in previous years. Other than a speaker who (to me suspiciously) grandly extolled the virtues of sitagliptin, the obvious and indirect commercial message was subdued compared to past years. The speakers were professional, competent qualified and (except as described above) appropriately restrained.

And my lunch - half of a plain turkey sandwich, diet coke and an apple. Healthy, but not necessarily "free."

Maybe We Can Help The Auto Industry?

It takes a crisis to end our lethargy, a crisis which convinces us that aggressive lifesaving, previously unthinkable, action is needed.

We have our crisis. GM, Ford and Chrysler are moribund, in part, because of crushing health care costs. The Big 3, and its entire American supply chain, is burdened by excessive health care costs, adding to inflation in the price of American automobiles and automobile related services paid by American consumers. America's auto industry is emblematic of our lack of competitiveness in the global economy.

It's time for the multifaceted approach described in my October 10, 2008 blog . Bail out American industry, including but not limited to the auto manufacturers, by giving them a level playing field in global commerce: remove their burden of crushing health care costs by enrolling the entire auto industry's workforce in a plan which is equivalent to that available to Congresspeople, preferably one which has a federal component which (on an even-playing field) competes with major health insurers and systems. Will the public lose? Not if American automakers can sell "green" reasonably priced cars; not if plummeting employment begins to rise again; not if Americans can pay their mortgages and send their kids to college because they are working and optimistic; not when hope is restored to capital markets; not when America is already paying for health care costs which include a 25% wasteful administrative overhead for some insurers; not when millions of Americans have no health care insurance and either don't pay or become public charges; and not when appropriate regulatory oversight of the American automobile production industry is included.

We have a crisis which may soon reach epidemic proportions. We have reasonable solutions at hand which may remediate the health care financial drain on our collapsing economy. Before the patent's eyes close and rigor mortis sets in, let's take action.

Believe The Brown Journal

Although the New England Journal of Medicine (NEJM) now comes every week by mail without any cover, it used to come in a tan paper wrapper.

One day, as a colleague and I discussed a NEJM article, we discovered that each of us would let the NEJM stack up until the wrappers turned from tan to brown. Then, as with ripe bananas, it would be time to open them and digest the contents. Until the wrapper was brown, there had not been enough scientific scrutiny to trust claims made in the journal's articles.

On Monday November 11, the NEJM article on the use of a particular statin in a "low risk" population with satisfactory cholesterol levels but high CRPs (C-reactive Protein, a marker of inflammation) attracted a great deal of media attention. Experienced physicians will probably wait for several months before letting the article provoke them into prescribing the statin in question for the reasons promoted in the article. By the time the "brown journal" has matured in four or six months, the data will have been scrutinized carefully, appropriate questions will have been asked, biases will have been exposed, the drug company sponsor's biases will have been evaluated, the issue of possible conflicts of interest among the investigators will have been considered, and conflicting medical-scientific questions and issues will have been brought forward.

If you ask most young physicians about the "brown journal" they won't know what you are talking about. If they believe today's news, without paying attention to the information about the study that is still to come, they do you, the patient, no favor. And if you are dubious about my hypothesis, go to any medical library, take a ten year old journal from the shelf, read the drug advertisements, and ask yourself why those drugs disappeared and are no longer used.

Dear President-Elect Obama

You have staked your political and personal reputation on your promise to reform health care, make it more effective and more cost efficient. My guess is that you have surrounded yourself with experts who tell you that the federal government can save enormous amounts by managing and coordinating disease care for high risk people. These high-cost patients, many of them poor, elderly and not well educated, with multiple diseases, use enormous amounts of government funds for their care. Obviously, your experts will say, spending money on managing disease care through insurers or other plans, telephonically or by personal contact (with such interventions as providing transportation, medication or social service support), makes sense.

As a lawyer and former President of the Harvard Law Review, you know very well that all that is in print is not true, that experts can honestly hold to strong but incorrect opinions, and that one should be skeptical of claims by anyone that he or she has "the" solution. Please use those skills in evaluating the hype about disease management.

The managed disease care solution falls apart under close scrutiny. The Fall, 2008 Health Care Financing Review, in an interesting series of papers growing out of disease management studies conducted by Medicare and Medicaid, shows that savings, if any are negligible. Brown and Peikes (15-Site RAndomized Trial of Coordinated Care in Medicare FFS") found that after two years, the treatment group experienced no gross or net expenditures savings when compared to the control. Esposito and Brown reported that a primarily telephonic patient monitoring and education service "show virtually no overall impacts on hospital or emergency room . . . .use" although for a subset of patients with congestive heart failure program reduced Medicare expenditures by 9.6 percent. In the paper "Evaluation of Medicare Health Support Chronic Disease Pilot Program," Cromwell and McCall's conclusions were consistent with the cited authors' interpretation of their data. Goldfield and McCullough's paper, "Identifying Potentially Preventable Readmissions" unsurprisingly showed that "readmission rates increase with increasing severity of illness and increaasing time between admission and readmission, vary by the type of prior admission, and are stable within hospitals over time."

Treating elderly individuals with near end-stage severe chronic disease and mental health illness, will absorb enormous resources with very limited benefits. Providing a significant portion of those resources to young Americans, and using less expensive culture-changing methodologies, may yield better long-term results. America needs to resolve its ambivalence over tobacco, alcohol, addicting substances, unhealthy food intake, exercise and work habits. It should facilitate education for all of our young people and devote adequate resources to building a healthy life foundation for our country.

Good luck, Mr. President-elect. My grandchildren's well-being will depend on the decisions you make.

A Brave New World - But Who Can Afford It?

The doctors' lunch table discussion on Thursday, Nov. 7, was a little different. Since the only oncologist in the group had left practice, we did not discuss the inability of oncologists to pay for an office stockpile of expensive chemotherapy drugs for their patients and the difficulties this caused for patients, oncologists, hospital and infusion centers to which these patients were referred for treatment. The difference yesterday that the complaint came from a new source, an experienced community nephrologist who described an insured kidney failure (not on dialysis) patient who need erythropoietin to produce blood. Because the doctor's practice was not generating sufficient income for him to stockpile a supply a erythropoietin, he gave the prescription to the patient whom he told to procure the drug and bring it in on the next visit. The patient came, but without the drug, saying that he couldn't afford the $500 prescription charge. This doctor went ahead and took care of the patient's need, giving him the medically appropriate dose of erythropoietin, but sent letters to the rest of his patients informing them that he will be unable to do this for them.

Recently, there have been studies and journal articles about the risks of giving too much erythropoietin. But less dramatic information about the difficulties patients are having in getting, paying for and benefiting from standard accepted medical therapies grab no headlines. As we move into a period of extraordinarily effective biologic products which relieve pain, suffering and premature death, our health system will have to grapple with the high costs of these products and their unavailability to many who need them.

What Is The Lesson of Obama?

The election of Obama teaches us, not only that a well-organized, dedicated and competent electorate will respond to an articulate smart and sensible leader, but that it will recognize its legitimate self-interest and take forceful action.

That lesson is applicable to our health care system. The Clintons tried to design a hierarchical system from the top down: it didn't work. Let our united voices help build a system, from the bottom up, which provides affordable appropriate necessary health care to all Americans. See my blog dated November 6, 2008,write your letters, and make your voices heard.

Voters: Set The Health Care Agenda

When Congressman Norman Mineta and I had a discussion about health care reform at his annual barbecue in the mid-90s, Norm, a very smart, seasoned and common-sensed San Jose Democrat, felt that neither Congress nor the Administration at the time was ready to act. As usual, he was right

Although health care has even greater public importance today, unless it's a high profile item on the national political agenda, nothing substantive will happen. Partisan politics, budgetary priorities and shortfalls, and our economic woes will block reform of our health systems. Major donors (i.e., insurers, hospitals, pharmaceutical manufacturers, chiropractors organizations, nursing homes, nursing associations and unions, physicians' lobbies, various unions and many others) will preserve their privileged positions. The public, patients and their families, will once again be ignored or stalled.

It's time for voters to use some of their chips - to write brief clear letters (especially the kind that go in the Post Office mail) to our Representatives, Senators, the Administration, and national political parties, making it very clear what we expect them to accomplish for health care. (If you can't write a letter, send an email, but note that email is not as effective at influencing political judgment.)

If you choose not to use your political chips, those major donors to the Republican and Democratic parties, candidates and functionaries, will be at the health policy table in a no limit to the stakes game. Setting an agenda in which health care needs are trivialized, they will divvy up the health care pot, and the public will once again be screwed. You can make a difference by writing a one page letter to your Congresspeople, the Republican and Democratic national parties, the Obama Administration, and your local newspaper:

!. First short paragraph: tell the recipients who you are, where you live, and that you are a voter in their districts (use your zip code); briefly describe the single most serious health system problem you have found.
2. Second short paragraph: describe a solution to the problem you have identified and describe the single most important thing that you want them to do.
3. Third paragraph: picture for them how your proposed solution will help.
4. Fourth paragraph: tell them why their advocacy for your solution to the problem you have identified will be in their best interests.

Politicians count numbers. If enough of us write to our politicians they will notice and respond. If we set their agenda, they will follow. After all, they work for us.

Who Pays For Research?

Today's questions:

1. Should scientific health research (as distinguished from research on the organization, process or payment for our health care system or military health research) be funded by the federal government? If "yes", should the budget for such research draw on funds collected by the federal government for health insurance or from some other source? If "no", where will adequate funding be found?

2. What percent of the gross domestic product should be used to fund scientific health research? What fraction of that percent should come from government and what fraction should come from non-government sources?

3. What percent of the gross domestic product should be used to fund research on the organization, process or payment for health care? What fraction of that percent should come from government and what fraction should come from non-government sources?

4. Should government play a role in encouraging scientific health research?

5. Should a private funder of scientific health research have patent rights from discoveries which it can then market? Should a government funder of scientific health research have patent rights from discoveries which it can then market?

6. Should a federal regulatory agency, such as the Food and Drug Administration, draw its funds from industry and the manufacturers of products which are submitted for approval?

7. How many cents of the health care dollar which come from your pocket should be used for scientific health research?

Re-Forming Our Health System: Some Questions

Here are some basic questions relevant to re-forming our health system:

1. Who should define the issues pertaining to reform of our health system?

2. How should the decisions on issue definition be made?

3. Is health care a right? If not, why not? If so, what are the corresponding obligations and upon whom should they fall?

4. How should decisions be made when multiple individuals are competing for the same health care, but limited resources require that only one receive the care?

5. Are there any groups in our society that should have preferred access to health care?

6. Are there any groups in our society that should have restricted access to health care?

7. What proportion of our national economic resources should be devoted to health care? To Public Health? To personal health services?

8. What proportion of our individual economic resources should be devoted to our health care?

9. Should our health system provide a uniform standard of care, or should individuals receive health care based on their religious, ethnic, customary or other beliefs?

10. Should we have professional licensure and institutional accreditation performed by the states or solely by the federal government?

Incomplete Truths, Cost-Benefit Economics & Health

In the last eight years, some Americans have learned that pragmatic national political "security" decisions, unencumbered by moral or ethical considerations, leads to national malaise and international disrepute. This principle applies equally well to any proposal concerning our national health system. Health care expenditures deserve much more than economic cost-benefit analyses: they involve people's survival, lives, families' well-being, and a deep-seated American sense of fairness.

I eagerly read the October 23, 2008 New England Journal of Medicine articles by Victor R. Fuchs, Ph.D. ("Three 'Inconvenient' Truths") and Karen Davis, Ph.D. ("Slowing the Growth of Health Care Costs - Learning From International Experience"), both of which focus on the economics of health care and suggest directions to be taken (www.nejm.org - by subscription). Sadly, neither mentions the moral and ethical foundational questions which must be answered before the architecture for a new healthcare system plan is prepared.

When are we going to convene a serious national discussion of the moral and ethical principles (including goals, objectives, priorities and rules) which must underlie changes to our health system? Is it all economics, pragmatic decision-making and political gain, or will we work towards a health system that we can live with?

A Time For Forgiving Credit Card Health Debts

In the Jewish religion, for more than two thousand years, this has been the time of year when Jews were commanded to forgive the debts, and interest on the debts, of indigent citizens.

These days, people undertake to pay for health care with credit cards. Patients and their families have little understanding of how quickly costs will mount, expenses will grow, and their resources devoured by sickness, by professional fees, hospital costs and ancillary services. Insurance pays only a portion of health care costs: the remainder goes on the credit card.

In America, health care credit card debt will not be forgiven, no matter how pressing the need for services was, how dire the patent's situation, or oppressive the health care service provider's billing practices might be. Congress has prevented credit card debt from being discharged in bankruptcy and, as a bankruptcy judge told a group of us who were assembled at a bar association meeting, medical services charged on credit cards are a major cause of patients' (and their families') financial collapse.

In this season, isn't it time to forgive the credit card debt, and interest, incurred in preserving life and health? If we can extend help to bankers, investment and financial firms, and others whose debt was incurred in pursuit of satisfaction of their greed, can't we protect - through a return to permitting bankruptcy discharge - those whose credit card debt was incurred to save lives and health?

Health & Wall Street CEOs - Some Similarities

Large non-profit health systems boards tend to be fairly homogeneous. Individuals, matched to matrices, may reflect different genders, races, ethnicities and religions, but the board members tend to be recruited by board officers (often after being identified by systems' CEOs) for the conformity with the outlook and philosophy of the existing board and the person who identified or recruited them.

Depending on the precise terms of the employment agreement between the CEO and the system, it is not unusual to have a reopening/renegotiation of the CEO's employment contract every few years. That process may be handled through a small committee of the board including the chairperson, the vice chairperson and the chair of the board finance committee which conducts most of its work privately. The CEO provides access to industry comparable salary levels with which the committee works.

Sounds reasonable, doesn't it? But ask: who selects the board chair, vice-chair and finance committee chair? Although they are appointed by the board and are independent, the CEO often has a lot to say (often helping to identify them to serve on the board and keeping them in his or her loop).

And how are the industry-comparable salary figures generated? One way is through surveys by large employment consulting companies which query other CEOs' institutions as to what they are being paid. The results in a leveraging of salaries as CEOs provide information which shows increasing salaries for their class of employment. If no contract agreement is reached, the CEO knows which employment consulting company will offer help in finding a new job and the consulting company knows who is looking for a CEO position.

Then, something very interesting occurs. Each board dreads the idea of firing its CEO and going through the painful process of having a fill-in CEO while a job search is done. And (perhaps biased by their own image of accomplishment) boards tend to believe that their CEO is better than average and thus worth more than the average.

So, as the health care delivered by an institution becomes more mediocre, and the institution exports its problems to other institutions (making itself more profitable)CEOs' salaries rise.

Sounds just like Wall Street financial executives, doesn't it?

My Stupid Mistakes

A reader asks me, not about others' medical mistakes, but about my own.

Here's one - my full responsibility - that almost cost a life.

It was warm and muggy in Washington, D.C., where I (traveling with my wife and son) attended a board meeting of the National Health Lawyers Association. One evening, the three of us strolled through the mist to the Lincoln Memorial. Walking back, I felt an unfamiliar uncomfortable pressure in my chest. As a physician I was well-equipped to go down the differential diagnosis list. High on the list - acute coronary artery insufficiency. Not as high on the list, esophageal spasm. I did what a lot of doctors do when they are making decisions about their own health: I chose to ignore the most serious diagnosis. Without sharing information about my quickly resolving discomfort, I used a beginning Washington drizzle as an excuse to take a cab back to the nearby hotel.

Two weeks later, back in California, Sunday shopping at a crowded Costco, the discomfort returned, worse but shorter in duration. If a patient had called me with that complaint, I would have demanded that he or someone with him call 911 for an ambulance and emergency hospital evaluation. I didn't call 911 and when the discomfort passed, I finished shopping and went home.

I didn't consider my complaint a "flashing red light and sound the sirens emergency," but, realizing that my denial was stupid, did see my physician the next day. I had my treadmill (my cardiologist partner's face told me everything I needed to know within two minutes of beginning the test), and went on to have successful surgery nineteen years ago.

Yes, it's true: the doctor who diagnoses and treats himself has a fool for a patient.

For my readers: If you develop the symptoms I described, tell someone with you what is happening, immediately call 911 (or have someone call for you), demand emergency transportation to a hospital, and let a competent physician and team evaluate you. I was lucky: you might not be.

The Value Of A Medical Service: III

I returned to my office, one afternoon, to a phone message that a doctor whom I didn't know needed me immediately. An abortion at a local surgical center had serious complications. The patient was bleeding.

At the center, I saw an unconscious bleeding patient in shock on the surgical table. The OB-GYN explained that the procedure had been without incident until suddenly she bled from every orifice. He told me that the patient had been in excellent health prior to the procedure and that there was nothing else unusual about her case. We both knew that the situation had progressed beyond his skill level and that the patient was facing death.

She had experienced an amniotic fluid embolism resulting in disseminated intravascular coagulation ("IVC"), an uncommon complication of term deliveries and early termination of pregnancy. Sometimes IVC, in which blood abnormally clots throughout the vascular system, exhausting the body's supply of clotting factors, is self limited, but not in this case. There was no time to waste. Lab tests were quickly drawn, massive amounts of red cells and platelets provided by the American Red Cross were available and administered, and supportive intravenous fluids and medications were given. The patient's bleeding ended.

The OB-GYN and I had a few moments to talk. He now told me that the patient was a sixteen year old whose parents did not know she was having an abortion. He told me that she was a member of a religious group that did not approve of abortion or blood transfusion. He told me that she was a Medicaid patient.

I wrote my consultation note, decided that there would be no charge to the patient for the time I spent with her that afternoon, and after evidence that her vital signs were stable - that she was no longer at risk of bleeding to death - told the OB-GYN that I would be leaving but would remain available for emergent care. He told me he had a social engagement in a nearby city and asked if I would take over the patient. I told him that the patient was his responsibility and that he should cancel his social engagement.

I never heard from him or the patient again.

Government Printing Presses Are Running

Historically, health care inflation is greater than general inflation. The availability of sophisticated diagnostic equipment and testing, use of new technology, and new expensive treatments have been responsible for this inflation. In those periods when government attempted to control health care inflation through price controls (Nixon) or limit access to new technology (Health Systems Agencies), these efforts postponed but did not limit inflation. Historically, attempts to control health care costs have delayed the introduction of new life-saving technology and treatment, which is not a sensible direction to pursue.

America's printing presses are running overtime printing dollar bills to correct for America's incompetency in regulating our financial industries in their obscene boom and bust activities. Inevitably, massive government spending of money it doesn't have is followed by another form of economic instability - severe inflation, a component of which is likely to be even more severe health care cost inflation. The elderly, in particular, who depend on fixed income and have no hedge against inflation, will be hard put to meet the inflated costs of health care, and particularly pharmaceuticals, if we continue our current system of financing and providing care. Those whose assets are depleted or destroyed during our current depression will be unable to create a financial cushion to protect themselves against health care inflation and may increasingly be unable to afford (or their employers may be unable to afford) health insurance. In short, our health care systems' troubles, while not attracting as much attention as the collapse of our banking, credit, insurance and financial systems, place us standing on a banana skin on the brink of a deep precipice. This is made all the more difficult because health care purchased with credit cards is essentially shielded from bankruptcy protection (another gift of our Congress to the credit card industry).

Neither Obama nor McCain is dealing seriously with these impending threats. The plan that I proposed in my last blog is a lifeboat which holds some chance of being able to provide appropriate health care in the time of economic turmoil which we have entered. We need real substantive change in our health system, not just words which are decoupled from action.

An Immodest Health Care Proposal

The October 9, 2008 perspective articles under the names of Obama and McCain in the New England Journal of Medicine lack new ideas, specificity and detail.

Here are my dozen proposals for readers to consider, react and respond to:

1) provide contractual direct tuition subsidies for qualified students to receive education through accredited institutions, in critically important personnel-short areas of health care (physicians in certain needed fields, Ph.D's in patient-care related areas, nurses, physician assistants, certain radiologic and lab personnel and others).

(2) Subsidies will require a two-years of work for one-year of subsidy payback in an independent-chartered federal health program. While working for the program, pay would be less than the person would earn in "private" practice, but considering the tax benefit and loan interest-savings of the subsidy forgiveness, the person would financially benefit.

(3) Put these people (in addition to those who, without subsidy, choose to work for the program)to work full-time in cities and other areas where they are needed in federally run health facilities open to selection by all Americans.

(4) Couple enabling legislation with the requirement that all Americans be insured through their employers, privately, or through government programs at precisely the same premiums for exactly the same range of benefits available to Congresspeople. For those who cannot pay, federal financial support will be needed.

(5) If private employers or insurers offer "Cadillac" benefits, they can do so as supplemental insurance programs at any price they wish, but such employment benefits and "Cadillac" insurance will not be tax exempt or deductible.

(6) There will be no "networks" of providers: as with Medicare, essentially all licensed health care providers, including hospitals, will serve all Medicare and private plans without payment differentiation from plan to plan.

(7) Continued provider participation will depend on providers' provision of care (and compliance with applicable law) meeting generally accepted professional and institutional standards. Individuals will be able to change programs every two years.

(8) Those coming into the programs after the first year will be assigned to the federal or private programs (to the extent the private programs wish to increase their subscriber base) through random number generation so that insurer "cherry picking" (which tends to exclude individuals with rare diseases and health history problems) ends.

(9) A scientifically appropriate federal formulary will be available for all of the programs; prices of drugs will be negotiated at arms-length federally. Program quality standards and compliance will be federal functions, will be free from political intervention, and will be based on scientific recommendations from non-conflicted scientific panels. Appeals will be heard through an administrative appeal system.

(10) The federal government will collect all premiums and pay insurers (or for those enrolled in the federal program - the program) directly at a set contract price. Providers will receive the same fee for the federal and private insurer programs. Any physician or provider which "opts-out" of the program will receive payment distributed from what is left of the premium pool at the end of each year, if there is any surplus. Providers will not be permitted to balance-bill.

(11) The federal program will develop, test and use electronic medical records. Other systems and providers will have their claims paid electronically after valid electronic claims submission. Providers would be encouraged, but not required, to institute electronic medical records with significant federal financial support.

(12) States will be required to provide care for non-citizens who require emergency health services or health services which are required to protect the public from injury. The Medicaid program will be eliminated.

A Question From Anonymous

On Fri, Oct 10, 2008 at 10:59 AM, Anonymous wrote:

"How does this folksy anecdote relate to the bigger theme of your blog?"



A priest, functioning in a hospital, is as much a part of our health care system as the daughters who run Catholic hospitals, Jews who operate hospitals such as Mount Sinai in New York, and other religion based providers of health care who have a long tradition of service in this field. If our only view of our health care system is people wearing white coats, we are wearing blinders which we need to take off.
Henry P. Kaplan, MD

Aren't We All Terminal?

Jeanette (not her real name) had reached her late 50's and knew that she was facing death. This strong cheerful Hispanic lady had a chronic blood disorder which was rapidly worsening. One afternoon, she told me that she had agreed to a local television interview because she thought it important to tell people about her life, her leukemia. and her experiences as a patient. She told me it was important that I watch, too.

A week or two later, back in my office, we talked about the television interview and she wanted to know what I thought of it. I told her that it was excellent, but at one point I thought she had been very angry. She agreed saying that the interviewer had repeatedly described her as "terminal". "Aren't we all terminal one way or another?" she asked.

A week later Jeanette was in the hospital, dying. We were talking about death and she showed that flash of anger that I had seen in the television interview. "What's going on?" I asked. "Why are you still here?" She told me that she was ready to go, and her family was ready for her to die. And then she said: "It's my priest who comes to see me every day. He's given me the last rites, but he's afraid of death and won't let me go."

When I returned to my office, I called another priest at a local Catholic Church, and reached agreement with him. I visited Jeanette at noon, the priest visited her at 2 p.m. and by late that afternoon she had peacefully died.

Will Anyone Pay For Your Care?

Last week, a drug company bought lunch for me and a group of physicians. There was no sales pitch nor a discussion of any drug. The drug company representative sat and listened as physicians discussed their increasing difficulties practicing medicine.

One of the doctors told his consultant that he was going to stop sending him patients because consultations were being scheduled two to three months after the patient called. The consultant, in turn, complained that he was experiencing a practice-crippling "no show" rate of fifteen percent, notwithstanding confirming calls the day before appointments. He and other physicians described increasing difficulty in collecting accounts receivable in a timely manner from payers. They complained that their staffs' energy, and their own practice time, was being wasted by insurers who refused or delayed authorizing medicines for individuals with serious medical problems. They observed that loss of employment means that one day a person has health insurance and the next day she doesn't, and won't show up for a needed medical appointment.

I asked whether any of these physicians had ever asked to see the financial statements of the HMOs, PPOs and indemnity insurers with which they do business and have burgeoning accounts receivable? Had they ever considered that they were at risk of non-payment because the companies might be under financial pressure, like other financial institutionsin our depressed economy? Had they thought about the possibility that payers were not approving medications because they were having cash flow problems?

Not one physician had considered doing what small businesses know: beware of financial weakness in businesses that owe you money. Although one physician group in the area in which these physicians practice had declared bankruptcy several years ago, leaving some of these doctors with substantial losses on accounts receivable, not one physician had factored the concept of business risk into his or her financial plan or willingness to contract with, or render services to, patients of HMOs, PPOs and indemnity insurers. Many of these physicians were driving down their own income by doing business with companies which paid substantially less than the rate paid by their average payers which in some cases, was less than the physician's cost of providing services (allowing these companies to grow by undercutting the rates charged to employers by better paying payers).

Under these circumstances, would anyone actually expect physicians to oppose a single payer system? Not likely!

The Value of A Medical Service - II

John was a pleasant man with late stage polycythemia rubra vera, a chronic disease in which the body makes excessive blood: too many platelets, red cells and white cells. Eventually, his bone marrow failed as it was replaced by fibrous tissue. Other organs made his blood cells.

I had followed John, a retired engineer, for years. In addition to the usual medical issues, we talked about his family, his church work, his computer programming and other activities. Gradually, John's blood counts worsened, he stopped eating normal meals because he filled-up too quickly, and his spleen sat in his abdomen like two professional-sized footballs, lying side to side. John needed to have that enormous spleen removed.

It took more than two weeks to find the right doctors: a general surgeon to perform the high-risk operation, a vascular surgeon who specialized in capturing lost blood so that it could be given back to the patient, and other members of the support team. Finally, John came to the brightly lit and crowded operating room where his surgery began. His huge spleen was glued to his left diaphragm (the muscle which moves air in and out of the lungs). Surgery was difficult and bloody. The team spent five hectic hours dissecting and removing the spleen, dealing with John's massive bleeding, capturing and recycling John's blood, transfusing John with blood components from the Red Cross, and dealing with John's unstable vital signs.

Finally, the surgery was over and John was in the recovery room. I left the operating room to tell John's family and friends how he had done, indicating that their prayers may have played a role in his positive results.

Two weeks later, John was in my office. His enormous abdominal mass was gone. He was eating again. His blood counts were dramatically improved. A month after his surgery John was feeling better than he had in months. That's when he told me that, because he found that he could buy health insurance for five dollars less per month, he was moving to a different plan and wouldn't be seeing me any more.

The Value of a Medical Service

This is the story that Emmett Henderson, a Harvard-trained urologist told me.

One warm July 4 Sunday evening, his answering service connected him to his long-term patient "Joe" - a local plumber. They agreed to meet in a local hospital emergency department at 9 p.m. where Emmett spent an hour successfully attending to Joe's problem. When Joe offered to pay him, Emmett deferred, saying that he would send a bill.

A few days later, Emmett received a furious phone call from Joe who, incensed about the fee amount, accused him of being unscrupulous, of overcharging, of being a robber and a thief and without conscience. Emmett listened without comment and then explained that, on the first workday after the July 4th weekend, he had called the plumbers' union, had inquired how much it would cost to have a plumber come to his house on Sunday night, July 4 for an hour's work and that's what he billed Joe.

Joe paid the bill without further protest.

Restoring Healthcare to Our Suffering Economy

My take on the presidential candidates health care reforms: McCain, no real plan, no change; Obama, the country's financial collapse trumps any consideration of health care reform in the immediate future.

Our economy is sick. People, whose homes have fallen in value, whose retirement savings are rapidly shrinking as bonds, stocks and saving wane, feel poorer. American jobs (not already lost) are in jeopardy. Families' confidence in their abilities to pay mortgages, credit card debt and other obligations has diminished. Trips to the supermarket and gas station reveal prices which are substantially higher than they were a year ago. The unemployed, uninsured, underinsured, poor or about-to-be poor, or those depending on (federally subsidized) state Medicaid will not have access to, or be able to afford, necesary and appropriate health care. Is this really the time to ignore the health care system crisis because we have a national and international financial crisis?

Our country needs to ask whether the enormous resources being spent today on health care buy health care. Do dollars spent to offset insurance company or health plan marketing costs buy one doctor's office visit or one school nurse's office, or one vaccination for a child, or one bottle of insulin for a diabetic? Health insurance sales commissions don't buy health care. Does 25% of the health insurance or plan dollar buy health care? No, it buys administrative overhead, and no administrative overhead has ever cured a sick father, delivered a newborn, or taken care of a child with cancer.

Our federal employees, including Congresspeople, have an excellent menu of health services from which to choose. These plans are not burdened by high marketing and commission costs. Medicare is efficiently run and does not need high administrative overhead to get its job done. Let's piggyback onto these systems, providing accessible lower cost insurance, which provides needed, professionally accepted standards of care to all. Let's start by providing access to insurance through existing mechanisms which have proved track records.

A Question From Anonymous

Anonymous asks: "Wouldn't the patient be better of [sic]if his or her gp hands them off to a specialist better qualified to handle his or her specific disease?"

Response: Let's suppose that you had seen your OB/GYN physician once or twice a year for twelve or thirteen years, the OB/GYN had operated on you and diagnosed advanced ovarian cancer, and before sending you to an oncologist, had carefully avoided telling you the diagnosis, what it meant and his plan to never see you again. Would you trust that OB/GYN? Would you feel abandoned? Would you trust the oncologist or would you begin to wonder if the oncologist would abandon you, too?

There's a difference between a referral to a skilled specialist and abandonment of a patient. There's a difference between finding the most competent physician to deal with a life-threatening disease and dumping the patient on the new doctor without even having the courtesy to give the patient the diagnosis, the meaning of the diagnosis and explain the limits of your future relationship.

As one who practiced specialty medicine, I heard the complaints and anger of patients (and their families) whose doctors unceremoniously and without warning dumped them. The sunshine enema didn't mitigate their hurt, their doubts, their anger and their grief. Trust, and a working relationship between a physician and a patient is built on mutual respect and a willingness to discuss the truth.

The Sunshine Enema

The sunshine enema is not something advertised in your spam email inbox. It's quite different. You may have already had one, without noticing.

I was introduced to the sunshine enema, early in my practice, when physicians would send newly diagnosed patients with cancer or leukemia (or sometimes walk down the hall with their arms around their shoulders) to introduce them to me. The physician usually said something like this: this is Dr. Kaplan who specializes in taking care of people with your illness. He will be taking good care of you and you will soon be feeling much better. You won't need to see me any more because he is now your doctor. If your family has any questions, have them call the good Dr. Kaplan.

Lest you think this was a complement to me, be assured, it wasn't. It was a way to avoid the truth, shift professional responsibility to someone else, and to deceive the patient and his/her family, giving them the illusion that their usual doctor was honest and open. In fact, the usual doctor often hadn't even told the patient the grim diagnosis.

No one talks about the potential for "pay for performance" to cause physicians and other health professionals to cherry pick their patients and to send many of them on to other professionals "who specialize in taking care of people with your illness" rather than bear the professional responsibility, potential financial risk, and likelihood of being labeled as less than expert under the new system. Particularly if you, or a family member, has a rare, difficult to treat, or potentially very serious illness you may find yourself cherry picked right of your customary doctors' offices and into the hands of a new set of professionals who represent the new dumping ground.

When our political candidates tell us that they have a fix for what is ailing the health system, and paint glowing pictures of the bright new world ahead, they are giving us all "the sunshine enema." And it doesn't cause us a moment's discomfort - yet.

Chief of Staff Rounds

After I became the Chief of Staff of a large hospital, I met with its President and invited him to join me on morning administrative rounds every two weeks. Our first rounds took us to the intensive care unit where the chief nurse recognized and welcomed me. Then she turned to the Hospital President and said that visitors were not allowed in the ICU unless they were known members of a patient's family. When I quickly introduced them, and she realized that he was her boss, she was mortified; he did not smile.

A few weeks later we met again for our rounds and walked to the psychiatry inpatient unit. This time, the chief nurse recognized the President. Her welcome was the announcement that this was the first time he had visited the unit in over two years and she had been wondering when he would show up to see what was going on. She wasn't smiling and neither was he.

He never accepted my invitation to make rounds again.

As Much Time As They Needed

A. B., one of my early partners was an experienced Mayo-trained internist who had practiced long enough, in what was then a rural area, to have acquired a clientele of dairy farmers. A.B. loved his work, enjoyed collaborating with new young well-trained doctors, but most of all prided himself on his skill and his commitment to patients.

He had some quirks. When his dairymen called him at 3:30am, just before going to take care of their cows, and complained of minor problems, A.B. called them back at 11:00pm to find out how they were doing. He and they knew the limits of his patience, but he and they knew his competence, dedication and willingness to take care of serious problems at any time.

One day at 6:30pm, when A.B. was unlocking the practice's front door to allow a patient and her difficult husband to leave, the patient thanked him. The husband said, "Doc, I'll bet you will be unhappy when we have socialized medicine." Without any pause, A.B. replied "Oh no, under socialized medicine I would have been out of here an hour ago."

Today, we don't talk about socialized medicine. Our talk of health care reform, health care efficiency, pay-for-performance, economics, triage and universal health insurance has drowned out discussion of health care provider competence, commitment to patients, ethics and integrity. A. B. was certainly aware of the economics of practicing medicine, but he was never financially rich. When his heart gave out, and he retired, he retold the story of opening the door at 6:30pm, with wistfulness because he knew that the relationship between patients and their physicians was changing: the joy of medical practice was being replaced by the increasing burden of health care efficiency, payment for performance, health care economics and guidelines of care.

A.B. spent as much time with his patients as they needed, day or night; does your physician spend 10 minutes of undistracted time with you?

What Does "Pay For Performance" Mean?

September 8, 2008 NY Times has a fine essay on "Pay For Performance" (P4P) by Sandeep Jauhar, a cardiologist on Long Island, in which he discusses some "P4P" pitfalls .

The Fall, 2007 Health Care Financing Review (vol 29,Number1) is devoted to Pay For Performance. In Thomas and Caldis' introductory article, Emerging issues of Pay-for-Performance in Health Care the authors define P4P in economic terms: " . . . to include any type of performance-based provider payment arrangements including those that target performance on cost measures." Articles which follow state some less than rosy conclusions, such as "The bonuses are sensitive to disease manager perceptions of intervention, effectiveness, facing challenging targets, and the use of actual-to-target quality levels versus rates of improvement over baseline." Another article notes "Like all payment innovations, the P4P demonstration faces some challenges . . . .it remains to be seen how much control a demonstration participant can exert over its assigned beneficiaries when they retain freedom of provider choice and have limited incentives to restrain their use of services." A fourth article recognizes that without changes in physician behavior, the gains from redirecting patients from lower to high efficiency and quality providers are likely to be limited. Even the mechanics of statistical analysis, as described in a fifth article, are uncertain: ranking of small hospitals will be problematic.

Jauhar notes that legislation of professional behavior is likely to be associated with unintended consequences, such as physician avoidance of providing care to very sick, dying, high risk patients because they do not wish to be stigmatized by poor outcomes, or pressure upon a physician to treat prematurely or without knowing the necessary medical facts and test results. He describes the unthinking conversion of "guidelines" to performance standards, against which physicians are measured by hospitals, payers and Medicare.

In hospitals, medical staff members may labeled competent or incompetent, prudent or wasteful, good or bad, depending on whether their performance meets "guidelines" that were never intended to be mandatory. Jahuar describes Medicare's voluntarily physician self-report to Medicare on 16 quality indicators with financial rewards for compliance. Jauhar discusses the current "team" approach to medicare care in today's hospitals, in which it is difficult to assign either praise or blame to any of the many physicians, nurses, paramedics, respiratory therapists, surgical assistants, pharmacists, physical therapists and others involved in patients' care.

Driving P4P are economists, business people and economic analyses. The difficulty is that economists and business people are not physicians, and have no reason to understand that 50% of the the drugs, protocols and systems of treatment that they glorify today will prove to be either of no benefit or positively harmful in a few years. P4P focuses on efficiency ("cost control"), while claiming to promote quality, on maintaining the status quo, rather than innovative care which may prove to be better or worse than the "guidelines," and on satisfying marketing demands of payers who want to be able to claim that that their network contains "P4P" certified health care providers.

Jauhar has done the public a service by openly discussing P4P. Stay tuned: there's more to come.

Back To The Basics

It's fall, the season for kids to return to school and for the spectacle of stadiums full of football fans. Because we understand that our kids won't get a good educational foundation unless their schools emphasize the basics, we demand emphasis on the basics. We see that winning football coaches emphasize mastery of the basics and that winning teams don't get to the superbowl because of technology or gimmicks: they get there with hard work and competence in the fundamentals of football.

Those who plan and operate our health system haven't mastered the fundamentals. They focus on gimmicks such as unproved electronic medical records, grandiose medical edifices (Freud would have explained that they have edifice envy), complex PPOs, HMOs, copayment schemes, roadblocks of eligibility criteria, constructing barriers to payment, and creating rules which guarantee large numbers of uninsured.

I suggest we think about the basics. Let's educate our kids well enough in primary and high school so that they can learn to understand the world around them. Our colleges should be more than advanced high schools: they should help their students study social and scientific principles, to think, question, and develop a lifelong commitment to learning and to developing a respect for personal integrity and ethical systems. Our medical schools should be peopled with faculty who are not only scientists, but are expert skilled physicians, nurses and other health providers and planners who understand and value clinical care and value not just "the faculty agenda" but the art of teaching. We should encouraging the brightest and best of our young people to study sciences, medicine, health care and public service in an environment free of ethical conflicts of interest.

Our students should understand how they fit into society, why they will enjoy unique privileges and opportunities, and how to deal with professional rights and professional obligations which are in constant tension. They should be taught the use of constructive self criticism and correction, which are invaluable skills in science and health care.

And only then can we start to build a health care system that makes sense.

McCain's Evocative Speech

Today, I listened hard to the McCain's nomination acceptance for a fleshed-out health policy, but it wasn't there. We heard about oil and other matters - not about the issue that affects the health and well-being of all Americans.

But it wasn't a complete bust. His talk of honor, duty, country and his experiences in and after Viet Nam, tied-in with a discussion earlier in the day during a chance meeting with an old colleague, a health care businessman. Each of us, independently, has noticed the lack of commitment of many young physicians to their profession. They are 9-5ers who check in at 9, leave at 5, have no ongoing responsibilities for patient care when they are off, and live like any hourly factory worker. He summed it up neatly: the older generation gets out of bed in the morning and go to bed at night, knowing that they are physicians; the newer generation are physicians when they put on their white coats from 9 through 5.

It's no accident that each of us has chosen the same community doctor as personal physician since this doctor is imbued with the spirit that we value. His sense of self-worth, professional honor, integrity commitment and duty have not been diminished by trivializing and unrealistic television programs, administrative bureaucracies, arrogant obstructive payers, and destructive political rhetoric. He is a professional.


So there's real American value in what McCain said tonight. His personal values resonate beyond his military service. His military family was overt in its respect for honor, duty and country. My father was a lawyer who patiently explained to me, when I was a youngster, that a commitment to a profession and clients (or patients) is different from any other role in society in terms of trust, integrity and duty. Perhaps it's time to remind our physicians of this difference and the reasons that they are given their license and franchise by society.

Rat Poison & Medicare's Part D Doughnut Hole

The Kasier Family Foundation paper, "The Medicare Part D Coverage Gap Costs and Consequences in 2007", by J. Hoadly, E. Hargrave, et al., August 2007, analyzes Medicare beneficiaries' doughnut hole experiences in 2007, the first full year of Part D operation. Twenty-six percent of Part D enrollees reached the coverage gap (half by late August), which left them to bear the full cost of further 2007 prescriptions within the doughnut hole, and fifteen percent of these individuals went on to reach catastrophic coverage. Tha authors found that 15 percent stopped taking their medication, 5 percent switched to an "alternative drug in that class" and 1 percent reduced their medication use. 10 percent of the diabetics who reached the doughnut hole coverage gap stopped taking their medication, 8 percent switched to an alternative and 5 percent cut down on their medication use. The authors also noted that monthly outlays by the doughnut hole patients jumped from $104 to $196 during the gap.

One method, often and emphatically recommended by insurers to save money, is to purchase generics which are theoretically "bioequivalent" to branded products. Coumadin, the branded anticoagulant, is far more expensive than warfarin, the generic. As I mentioned in an earlier blog, an instance in which a patient returned a bottle of warfarin (a form of warfarin is used as rat poison) to a local pharmacy as "ineffective" (meaning, there was no discernable anticoagulant effect by blood test), sent a complaint to the Food and Drug Administration, and had no response either from the pharmacy chain or the FDA to the complaint, raises the question of whether the advice to purchase generics is always prudent. Compounding this specific warfarin problem was the recognition by some physicians in the area where this took place that warfarin supplied by the same pharmacy chain had provided inadequate anticoagulation to their patients.

So patients are in a bind. Spend their limited retirement funds on branded products which will place them in the doughnut hole sooner and aggravate their financial problems, or take "alternatives" which may yield suboptimal benefit and ultimately lead to uncomfortable, dangerous and expensive morbidity and possibly mortality. Or, they can just stop taking the medicines they can't afford to buy, perhaps using prayer rather than science to get through without bankrupting debilitation or death.

Of course, Congress could order Medicare to negotiate pharmaceutical prices for Part D patients, insuring product quality and affordability and ameliorating this unfortunate situation.

Obama Really Didn't Talk About Health Care Did He?

Obama's speech accepting the Democratic party nomination was short on plans for health care. He described his cancer-ridden mother's battles with insurers over benefits. He mentioned a plan for Americans which would give them Congress-like benefits. He spent a lot of time embracing, holding, and beaming at his family. But there was nothing of substance which could help 250+ million Americans understand whether he really has any health plan at all. We were entitled to more.

He could have said that he favored a single payer system with a available supplmentary coverage similar to the Medigap insurance that seniors on Medicare can purchase. He could have said a few words about setting up a truly competitive healthcare insurance environment in which qualiy and efficiency of health care can be measured to maximize benefit. He could have said a lot of informative things about his plans for health care. But he didn't.

How much money was spent by corporate health care interests to fund the Democratic Party convention? Will the big spenders be at the table designing the health care system that meets their organizational and financial/profit requirements without serious regard for public benefit? Will it be a glossed-over "business as usual" fix to our bloated, expensive and inefficient system? Or will Obama, if elected, and the Congress to be elected, get serious about fixing our ailing health system?

A number of years ago, at a meeting in Sacramento, the Senate President Pro-tem told me (and a few others from a powerful health trade association) that money did not buy his vote. He followed that statement by making it clear that money buys access to him and subsequent comments inferred that it might favorably dispose him to vote, some of the time. The rules haven't changed. Pay attention to who is funding the political parties, and their members, to gain access and influence opinion. If you do, you will be able to predict what our health system will look like in two years.

Fannie Mae, Freddie Mac & Your Family's Health Care

America is in a severe economic slump. Concurrently, the nation's health care costs, for a growing and aging population, are increasing. When the denominator (gross domestic product or GDP) shrinks or stalls, and the numerator (health care costs) grows, we will devote an increasing percentage of the gross domestic product to health care, giving politicians an excuse to vote against meaningful health care reform with health services for all Americans. I expect to hear the refrain "we don't have the money just now" from state capitals and Washington, coupled with the inference that health care is taking too big a bite out of America's economic apple.

The collapse of Wall Street, the exposure of our government to default on $5.2 trillion in mortgages (which you, the taxpayer, will be expected to underwrite), the lack of overall government credibility with its effect on individuals' and business' purchasing plans, and dismal newspaper headlines all affect the GDP denominator. A decrease in preventive medicine, early diagnosis and treatment, childrens' services and health technology, coupled with accelerating pharmaceutical costs, will eventually inflate the numerator.

As we move into the Democratic and Republican conventions, listen critically for realistic discussion of serious health care reform. It's your family's health and well-being they won't be talking about.

How Do You Picture Health Care?

Our usual perception, when asked to visualize health care, is a television image of an emergency room, a physician, a sympathetic nurse, and perhaps a paramedic. In reality, our images symbolize a failure of health care and its end-stages. We should be visualizing poor quality unsanitary food, poor quality housing, cultural conflicts, gang warfare, excessive (and often underage)alcohol use, poor quality water, poor quality and insufficient quantity of preventive health services, poor environmental conditions, the prenatal visit not done within the first trimester, the mammogram not done in the vulnerable woman, the testicle not palpated in the adolescent male who has a cancer mass which could be found and successfully treated, the school nurse whose services have been lost because of insufficient funding for our children.

Health care is a lot more than physicians, nurses, hospitals and ambulances. The determinants of health are often those issues which are arrogantly dismissed by politicians and planners because their political contributors don't want them to pay attention to those complex issues, and it is easier to provide political benefit to wealthy voters and their corporate allies than to the poor, nonvoters and our kids.

After all, how many minutes of political advertising, or seats at a campaign dinner, can the poor and children buy?

Obama: Does "Americans" Mean No Health Care For Uninsured Immigrants?

On August 5, 2008, discussing Barack Obama's health plan, I quoted his web site's language ("Obama will make available a new national health plan to all Americans") and commented "This still leaves states, counties and cities with the staggering financial burden of providing health care services for individuals who are in the United States illegally".

A recent publication, The Impact of Immigration on Health Insurance Coverage in the United States, 1994-2006 clarifies the significance of Obama's omission. This August, 2008 report by Paul Fronstin of EBRI (Employee Benefit Research Institute) describes and analyzes the 1994-2006 impact of immigration on health insurance coverage. (ebri.org/pdf/notespdf/EBRI_Notes_08b-20081.pdf).

In 1994 36.5 million persons in the U.S. were uninsured and that number climbed to 45.4 million under age 65 in 2006. While most uninsured in the U.S. are native-born Americans, Fronstin reports that in excess of 46 percent (more than 12 million) of foreign-born noncitizens were uninsured in 2006 (as compared to almost 20 percent among American citizens who were foreign-born and 15 percent among native-born individuals.

The report notes that California, Texas, Florida and New York are the states where the greatest numbers of the uninsured immigrants live.

Fronstin has helped to clarify the dimensions of the impact of immigration on uninsured health care in the U.S.

Obama's health plan will still leave states, counties and cities with the staggering financial burden of providing health care services for individuals who are in the United States illegally. His plan perpetuates an expensive cost-shift to cities, counties, states and their taxpayers and employers.

As a Harvard Law School Law Review editor, graduate and lawyer, Obama's choice of words and particularly his ambiguities, are significant. Words do count.

Obama: A Health Plan or Weasel Words?

Barack Obama's web site (http://www.barackobama.com/issues/healthcare/) neatly encapsulates his health plan. I have taken the liberty of interlineating comments (in bold).

Barack Obama's Plan
Quality, Affordable and Portable Coverage for All

* Obama's Plan to Cover Uninsured Americans: Obama will make available a new national health plan to all Americans This still leaves states, counties and cities with the staggering financial burden of providing health care services for individuals who are in the United States illegally, including the self-employed and small businesses, to buy affordable health coverage that is similar What does "similar" mean?to the plan available to members of Congress. The Obama plan will have the following features:
1. Guaranteed eligibility. No American will be turned away from any insurance plan because of illness or pre-existing conditions Will full benefits apply immediately upon enrollment or will there be a waiting period?.
2. Comprehensive benefits. The benefit package will be similar That word again. to that offered through Federal Employees Health Benefits Program (FEHBP), the plan members of Congress have. The plan will cover all essential Who defines "essential"? Right now, it may be a clerk in an insurance company's office who is not a physician or otherwise qualified to make decisions about essential care. Sometimes, it is patients' families whose expectations may not be consistent with standards of reasonable medical judgment. And as we saw a few years ago, sometimes Congress jumps in to make decisions concerning "essential" care. medical services, including preventive, maternity and mental health care.
3. Affordable How is "affordable" defined? premiums, co-pays and deductibles.
4. Subsidies. Individuals and families who do not qualify for Medicaid or SCHIP but still need financial assistance will receive an income-related federal subsidy to buy into the new public plan or purchase a private health care plan. Will they be able to purchase a plan which has a comparable network of providers and pays its network of providers the same amount as other plans?
5. Simplified paperwork This was the promise of HMOs, too. The paperwork was replaced by the requirement that physicians, other health care providers and hospitals spend hours on the telephone trying to get authorizations. and reined in health costs. What does "reined in health costs" mean? Does it signify that services will be cut in order to control costs?
6. Easy enrollment. The new public plan will be simple to enroll in and provide ready access to coverage. If experience is of any value, such plans have neither been simply to enroll in and financial constraints have made access problematic.
7. Portability and choice. Participants in the new public plan and the National Health Insurance Exchange (see below) will be able to move from job to job without changing or jeopardizing their health care coverage. This may be a major benefit. However, some employers may find that portability means that some talented individuals leave their employ because they are no longer constrained by a family member's uninsurability.
8. Quality and efficiency. Participating insurance companies in the new public program will be required to report data to ensure that standards Such standards are not described. Where will the bar be set? for quality, health information technology and administration are being met.

Healthcare The American Way?

Could our health care system be based on ethical principles?

America's founding documents reflect ethically supported principles of personal and governmental rights and obligations. That is how our country began.

A modest mom and pop shop or a large well-financed public corporation, will fail unless its owners and executives understand and articulate the business mission and pattern its business plan to fulfill that mission. Failure will be associated with a departure from the ethical principles, goals, objectives and priorities established at the beginning and revisited on a regular business. Whether it's "we supply fresh locally grown fruits and vegetables to our immediate community," or "we bring good things to life" or "do no wrong" those principles (and their ethical underpinnings) guide and center the successful business.

What is the clearly articulated mission of our health care system? What is the clearly articulated mission of each of its components? What are the ethical principles, goals, objectives and priorities that should guide its development and function? What are the ethical standards we are entitled to expect it to meet?

We have allowed our health care system to grow like cancer, draining resources and destroying our humanity for the benefit of transient political and business advantage while the patient is dying. Our system is more responsive to insurers, pharmaceutical manufacturers, durable medical equipment vendors, hospital lobbies, financial people, trade associations (often masquerading as professional organizations) then to people who can't afford insurance, mothers who do not have adequate obstetrical care, the sick, the poor, minorities and those damaged by poor food, air and water pollution, and public institutional indifference.

There should be an opportunity for every American to participate in the development of ethical principles for the development of our health care system through local, state-wide, regional and national forums. Those principles should be the starting point for Congressional overhaul of our health system. This should not be a Hillary Clinton type of mid-1990s paternalistic top-down proposal. It should come from the ground up and reflect our heritage as a democracy.

When Americans agree on ethical principles underlying our health care system there will be a visible standard to measure the performance of Congress and the Administration. Until the ethical consensus is achieved, rehabilitation, reform and improved efficiency of our system won't happen.

We need to get back to "the American Way" for health care.

What's Missing From Our Health Care System?

Our health system has insurers, system-integrators (HMOs and PPOs), not-for-profit and for-profit hospitals, physicians, nurses, other healthcare staff, pharmacies and pharmaceutical plans, ambulances, laboratories, diagnostic and therapeutic radiation equipment, medical schools, dental schools, professors of the healing arts, politicians making speeches about health care, state licensing boards, departments of health, a Drug Enforcement Administration, huge healthcare budgets at the local, state and national level, struggling employer health plans, tax subsidies, health care lawyers, health supply vendors, durable medical equipment, local, state and federal health investigative personnel, the National Institutes of Health, magazines devoted to health, electronic medical records and billing systems, administrative courts dealing with health issues, and a myriad of other health people, appurtenences, institutions and facilities.

With all of this, what is missing? An ethical context.



We have a highly regulated health care system which is political, pragmatic, irrational and emblematic of darwinian capitalism. It is spending too much for care which often is of questionable quality to give those, who can afford it, or those who have their bills paid for them (not necessarily those who need the care), the illusion of freedom of choice in selecting who will provide their health care and what their health care will be, as if obtaining health care is governed by the same criteria as choosing food from an elaborate menu in an upscale restaurant.

We should state our health care goals in an ethical context, develop priorities and time schedule consistent with those goals, build an efficient system for achieving those goals, and fund the system appropriately. We should hold those responsible for performance to high standards and refuse to accept the mediocrity which characterizes our current system.

What's missing? We have forgotten that health care cannot be separated from ethical and moral considerations and that the philosophy of survival of the richest and fittest is inappropriate when determining, apportioning and funding health solutions, services and products.