Fertilizer/Worldwide Farming/Health

See New York Times, April 20, 2008, Business Section, p. 1 for a brief discussion of the effect of fertilizer on individuals' growth, globally, as well as the effect of price inflation on fertilizer availability and use.

Energy Inflation and Health Care

What does energy cost inflation have to do with health care? As it turns out - a lot!

Health care is thoroughly enmeshed in the economy (consider - the cost of commodity supplies in the health care cost of living index has recently outstripped many other elements; malpractice insurers factor inflation into their premium structures because claims and settlements look forward for years; and hospitals and health care providers use large quantities of increasingly expensive energy). Not only will we have the usual increases in health care costs resulting from an aging population, increased requirements for innovative technology and treatment, intensivity of care, cartel-like market behavior, and other factors, inflation in energy costs will ultimately feed general inflation and have an additive impact on health care inflation.

Dollars spent for energy will not be available to employers or families to pay for increasing insurance or health care costs. Business closures or dislocations caused by inflating energy costs will mean that currently employed persons whose insurance is company sponsored, may lose their insurance or their ability to pay for insurance.

When the cost of energy is high, business and individuals seek dollar-cheaper energy sources. While the focus of the public is on low impact green energy sources (wind, water, solar), the big-money push is on to burn coal to replace or supplement petroleum-based energy sources. The coal industry has an extensive advertising program touting coal's low cost, plentiful resources, and ready availability. The advertisements do not discuss the track record of black lung disease in coal miners, black lungs in city dwellers exposed to coal smoke, nor the risks of acid rain, the release of strontium and other radioactive materials associated with the burning of coal, and the coal industry's troubling history of environmental degradation. The ads do not discuss the power-generating industry's sidestepping of clean air regulations through the use of grandfathering "add-ons" rather than the application of current standards to all current construction. Coal's immediate focus on dollar cost will seem like a bargain until we understand that the industry's cost-shifting will shift increased health care costs caused by diseases and environmental consequences of coal burning to the public.

There are alternatives. This is an incredible era of genetic exploration. The laboratory techniques which bring us a sophisticated understanding of the human genome could also be devoted to bringing genetic solutions to lower energy cost and availability. For instance, since nitrogen-fixing bacteria free legumes from the need for added commercial fertilizers, can we develop a gene-based nitrogen fixing technology which will substantially reduce the need for petroleum-based fertilizers on other crops? Can we use such a technology to produce biofuels, using marginal otherwise unfarmable land, while high-quality land, unencumbered by high doses of industrial grade petroleum fertilizers, is used to grow food essential for a healthy population. Can we move towards energy independence?

We have a choice: continue to destroy the environment, our health and our economy or use informed innovative science to help us deal with tough issues, such as energy and health.

Medicare Program to Show Advantages of Electronic Health

The American Society of Hematology's "The Hematologist" which arrived today carried the following announcement on page 6: "New Medicare Demonstration Program Aims to Show Advantages of Electonic Health"

"Medicare is looking for 12 communities across the country that can bring together a broad cross-section of community leadership, leverage resources, and recruit small and medium-sized primary care physician practices willing to provide the evidence that electronic health records (EHR) can improve the quality of patient care.

"As many as 1,200 physician practices nationwide could be eligible for incentive payments of up to $58,000 per physician - up to $290,000 per practice - over the five-year life of the demonstration. E-mail EHR_Demo_communityselections@cms.hhs.gov for more information."

Apparently, Medicare only wishes to learn about positives. Negatives are irrelevant.

What If Your Electronic Medical Record Is Wrong?

The Perspective column, by Robert Steinbrook, M.D. (pp. 1653-6) in The New England Journal of Medicine (N Engl J Med 358:16, April 17, 2008) describes social and medical complexities of computerized online medical records. Steinbrook describes the push towards online records provided by Dossia ("a nonprofit consortium of major employers"), "Google Health, Microsoft HealthVault and other Web services that are seeking expanded roles in the $2.1 trillion U.S. health care system." In other words, there is a lot of entrepreneurial money at stake (consider advertising revenues) pushing this project, which means that profit and return on investment may come first and patient health and well-being may move to lower priority. Since money buys political influence, beware when current Presidential candidates, Senators and Representatives talk about "health reform" and describe electronic medical records as the salvation to our health care systems' ills.

Based on my past experience as an attorney negotiating related issues, I am concerned about the risk that our medical records will become another commodity. After all, as I have described in earlier blogs, HMOs and PPOs have commoditized health care during the last fifteen years: why should our private medical records be different? Who will own the vital facts contained in your medical record? Will it be you, your doctor, your clinic, your hospital, Microsoft, Google, your employer, an HMO, PPOs, insurance companies or venture capitalists? Who will have the right to sell medical records if, for instance, a major repository goes bankrupt and the court system must dispose of the asset for the benefit of creditors to the highest bidder? What happens if a foreign company acquires the records?

The second April 17, 2008 article, "Off the Record - Avoiding the Pitfalls of Going Electronic," by Drs. Hartzband and Groopman (pp1656-8) takes a seasoned and cautious view of the electronic medical record. It describes the mindless repetition of information: "Senior physicians also cut and paste from their own notes, filling each note with the identical medical history, family yhistory, social history and review of systems." The authors warn that important new data may be obscured. Even the relationship between a physician and patient may be warped as the physician stands at the computer, focused on the screen, providing an impersonal detached experience for the patient.

My experience as a hematologist, taking care of very sick patients, highlights another issue which is scarcely mentioned. Previous physicians may be absolutely wrong in their diagnoses but the momentum developed in the electronic record may make it difficult to understand whether, how or why they went wrong. I saw patients with voluminous paper records from respected instutitions that diagnosed cancer when there was no cancer, that diagnosed essentially untreatable cancer when the disease was relatively benign, that made patients uninsurable because a doctor did not understand the difference between an adenomatous polyp in the colon and familial adenomatous polyposis of the colon and wrote a note which echoed through the chart for years.

Even competent physicians will, from time to time, look at a familiar patient with blinders of past experience, chart entries and sterotyped interactions. Sometimes, the safest record for the patient is no record (except for the list of medications taken and drug allergies provided by the patient) - which requires the physician to start from the beginning, as if he or she had never seen the patient before, with an open mind and challenges to every sacred diagnosis, treatment and prejudice which has affected their relationship and patient care.

Health Spending Causes Disinvestment in Our Kids

In "The 2008-09 Career Guide to Industries", the U.S. Department of Labor, Bureau of Labor Statistics, makes several significant points: in 2006, health care was the largest U.S. industry; and in 2006 it provided "13.6 million jobs for wage and salary workers and about 438,000 jobs for the self-employed". During the decade ending 2016, health care is predicted to add 21.7% more jobs (3 million new wage and salary jobs) than any other industry(www.bls.gov/oco/cg/print/cgs035.htm). In our recessionary economy, health care has become the engine for employment growth among both highly and lesser educated individuals, income generation (average earnings for nonsupervisory health care industry employees are more than average), and economic stability.

The Guide identifies nine segments of the health care industry: hospitals, nursing and residential care facilities, physicians' offices, dentists' offices, home health services, offices of other health practitioners,m outpatient care centers, other ambulatory health care services and medical and diagnostic laboratories.

About 30% of hospital workers are registered nurses though "Hospitals also employ large numbers of office and administrative support workers". Approximately 65% of the jobs in nursing and residential care facilities are in service occupations (nursing, psychiatric and home health aides). Physicians' offices employ 40% of their work staff ij office and administrative support occupations such as receptionists and information clerks.

A table in the Guide shows that management, business and financial occupations employ 4.2% of the health care work force, service occupations employ 31.8% and office and administrative support occupations account for about 18%.

In my opinion, America's older citizens are the group most likely to benefit from surging health care employment and resources. In an article in Scientific American a number of years ago, Bok wrote about America's increasing investment in the elderly and its disinvestment in its children. Wouldn't it be better to provide a health care system which provides efficient appropriate diagnosis, treatment plans, and quality of care for all Americans and focus the predicted 21.7% employment and resource "surge" on improvement of schools and services for our children? After all, those children will grow up to be the young adults who pay for the elder generations' health care.

It Wasn't A Free Lunch

A number of months ago, several physicians (I was one of them) sat down for a light lunch sponsored by a drug company which heavily promotes a drug on television to men with symptoms of prostate enlargement. After some chit-chat among the physicians, the two pharmaceutical company representatives launched into their permitted two minute presentation. They never got to finish. One of the physicians, an ophthalmologist, described the serious problems that the drug created for patients undergoing cataract surgery (which had been the subject of an article in a national ophthalmologic journal). Then one physcian after another express anger about the failure of the company and its representatives to be truthful and complete in their discussions of the drug with these physicians and in public advertising. For those two representatives, it was a learning experience: physicians become furious when pharmaceutical product safety is misrepresented through omission or comission.

I notice that the company's advertising now advises men considering the drug to tell their opthalmologic physicians that they take the medicine. Did the backlash from the physicians at the lunch table make a difference? Only the company will know, but you can bet that the experience has been replicated elsewhere and that some patients have been protected as a result.

Parallels: Big Steel and the Hospital Industry

Years ago I attended a program which drew parallels between the 1950s steel industry and the hospital industry. After World War II, the U.S. steel industry enjoyed a privileged position. It did not modernize, it did not introduce technology which was being developed in other nations to lower costs and improve quality, and it continued to pay dividends unabated. The failure of steel to recognize that devastating competition usually comes from an unexpected direction coupled with its failure to protect its equity base led to its near demise. Today, the US exports scrap metal which comes back to us from Asia as steel girders and finished goods. We are steel's third world country.

Many hospitals have incurred enormous debts (i.e., through bond issuance), engaged in a multitude of expensive marketing ventures, hired streams of expensive consultants (who generally tell them what they already know), paid extravagant salaries to their top executive staffs and, like the steel industry, failed to protect their capital bases. Whether an individual hospital or a hospital system is not-for-profit or for-profit, the financial pressures are the same: insurers, HMOs, government and employers are driving prices down below the level at which capital impairment occurs. The result is hospitals with fancy lobbies and executive suites and crowded emergency departments which make patients wait for hours before receiving service. The result is hospitals providing substandard services because they lack the volume or local expertise to improve the quality of these services, but are afraid to give them up because of marketing competition (or sometimes, physicians threats). The result is hospitals which disseminate messages that they are interested in caring for those who are basically healthy and that those who have serious expensive diseases should go somewhere else.

Hospitals are not going to be saved by grants, donations, government largesse or union busting. Hospitals will be saved by responsible stewardship and management, by responsible questioning boards of trustees and directors, and by active communities which demand - not grandiose facilities - but competent management of one of their most important assets.

What do you know about your community hospital? What has been the response to your inquiries about its financial health?

Polls About Pols and Health Care

Click on Kaiser Family Foundation's health08.org site for interesting information about politicians and their health care proposals as well as "non-partisan" polling which sheds light on public opinion/perception. The url is: http://www.health08.org/.

Medicare: Why Is Death So Costly?

The New York Times, April 7, 2008, p A17 reports that Dartmouth researchers found there is a huge unexplained variation "in the amount, intensity and cost of care provided to Medicare patients with chronic illness at the nation's top academic medical centers, raising the possibility that the government could save large amounts of money." The article focused on U.C.L.A. Medical Center and Mayo Clinic's main teaching hospital in Rochester, Minn. but the study included others facilities such as Cedars-Sinai in Los Angeles, Cleveland Clinic and New York University Medical Center in Manhattan.

The President of the Mayo Clinic interpreted the findings as consistent with his institution's practice of paying physicians a salary, which he claimed removes incentives for more aggressive treatment and fosters collaboration among physicians, staff, patients and their families. The chief medical officer at N.Y.U pointed to "a culture of physicians who have been very aggressive in their care and a patient population that has desired this type of care."

Were there other factors not discussed? A number of immigrant ethnicities have a strong culture of refusing assent to action which may shorten the life of a family member. In this era of "culturally sensitive" or "culturally competent" care, physicians, hospital staff and administrators have been trained to be highly respectful of the many cultures which their patients and patients' families hold dear and may prolong a patient's life to accomodate family wishes and to avoid adverse publicity, a complaint to Medicare by the family, or the threat of litigation.

If such conduct contributes to Medicare's unexpectedly high end-stage of life medical care costs, identification of key trusted cultural interpreters, who work with physicians, hospital staff, patients and their families, may help families and patients to accept appropriate medical care, and through appropriate care, to help prevent Medicare bankruptcy.

Senator John McCain's Health Plan

McCain's web site, Straight Talk on Health System Reform, can be found at:http://www.johnmccain.com/Informing/Issues/19ba2f1c-c03f-4ac2-8cd5-5cf2edb527cf.htm.

Like Clinton and Obama, McCain's program is very general, very vague, and very hard to pin down. No price tag is specified.

McCain sees health care cost inflation as a fundamental problem. He calls for (without specifying a mechanism) controlling costs. He advocates family control of its health care dollars and care and providing access to care. He speaks of providing flexibility to veterans allowing them to choose a provider that gives them timely care at high quality and in the best location. Without being specific, McCain calls for global reforming of the culture of our health system, the way we pay for it, and its quality. He speaks of promoting competition among providers and among alternative treatments, and empowering patients in preventive care and care. He favors an information rich health care marketplace with data concerning medical outcomes, quality of care, costs, and prices. as well as national standards for measuring and recording treatments and outcomes. McCain calls for greater Medicare emphasis on diagnosis, prevention and care coordination, but rejects Medicare payment for preventable medical errors or mismanagement.

On McCain's list is support for federal research on the basis of sound science resulting in greater focus on care and cure of chronic disease. He encourages flexibility at the state level through Medicaid innovation, alternative insurance policies and insurance providers and different licensing schemes for medical providers. McCain appears to endorse national or different licensing for medical providers which would allow them to practice nationwide. Like Clinton and Obama, McCain emphasizes modern information systems. He calls for market flexibility "in permitting appropriate roles for nurse practitioners, nurses and doctors: as well as use of telemedicine. McCain references community and mental health clinics in areas where services and providers are limited.

McCain calls for the development of routes for safe, cheaper generic versions of drugs and biologic pharmaceuticals and approves the development of safety protocols that permit re-importation to keep competition vigorous. He calls for tort reform, safe harbors for doctors that "follow clinical guidelines and adhere to patient safety protocols" and calls for vigorous enforcement of federal protections against collusion, unfair business actions, and deceptive consumer practices. He favors competition and innovation in insurance coverage and insurance portability. He proposes to reform the tax code to eliminate the bias toward employer-sponsored health insurance, and provide all individuals with a $2,500 tax credit ($5,000 for families) to increase incentives for insurance coverage. Individuals owning innovative multi-year policies that cost less than the full credit can deposit remainder in expanded health savings accounts. McCain favors individuals' ability to get portable insurance through any business, church, organization or association that they choose. This insurance will be portable across all jobs, and will automatically bridge the time between retirement and Medicare eligibility.

McCain promotes individual responsibility for health and illness prevention but favors education and public health initiatives.

Although McCain differs from the other candidates in at least one position (i.e., possibly endorsing a national licensing system for health care providers), like his competitors, he is vague on details and provides no cost figures or information on the revenue sources to accomplish his plan.

Words Do Count - As Obama Should Know

Senator Obama's web site (http://www.barackobama.com/issues/healthcare/)speaks of his health care plan on several levels of complexity. The "At a Glance" section talks of "Quality, Affordable and Portable Coverage For All", "Lower Costs by Modernizing The U.S. Health Care System", and "Fight for New Initiatives". The next level of complexity describes. in vague terms, such items as guaranteed eligibility, comprehensive benefits, affordable premiums, co-pays and deductibles, subsidies, simplified paperwork, easy enrollment, portability and choice and quality and efficiency. It goes on to describe a "National Health Insurance Exchange," employer contributions, children's mandatory coverage, expansion of Medicaid and SCHIP, and flexibility for state plans. It proposes to lower costs by modernizing the US Health Care System, ensure that providers deliver "Quality" care, lower costs through investment in electronic health information technology systems, lower costs by increasing competition in the insurance and drug markets, and fight for initiatives which appears to be a mix of politically appealing verbage.

Skip to "Background Questions and Answers On Health Care Plan" and discover that all of this will cost "us" taxpayers a mere $50-65 billion a year when fully phased-in. The basis for this number is not made clear: is it conjecture? Is Obama proposing an adjective laden piecemeal patch to the current system?

Not long ago we were told that $70 billion dollars (if my recollection serves me correctly) would cover our costs for the war in Iraq. It didn't, it won't and neither will Obama's health care proposal cost what it says in print on his site. He should provide a realistic tabulation of costs versus savings.

Obama's site does not explore the impact of his proposal on the economy, especially on the small businesses which are the lifeblood of American industry. It does not explain the impact of globalization on the offshoring of employment which allows major companies to get out from under health care insurance costs (and their pension costs) and shift them to others. It does not explain the risks of tinkering with a $2 trillion plus economic sector which, if it implodes, will make the current housing recession look like childs' play (health care is a major employer) as well as destroying the function we now have in our dysfunctional health system. Obama offers a simplistic fix.

In my opinion, Clinton and Obama suffer from a common defect. Each believes that she/he knows precisely what is wrong and exactly how the American people want their health care system to deliver services. My analysis is that they are wrong on both counts and that it would be better to start by having national bipartisan hearings to find out what is wrong and what the people want in the way of a health care system. Enough with the patriarchal approach - let's really have a sensible program for improvement founded in reality and the compromises which the American people will accept.

Words Do Count - As Lawyers Should Know

Senator Clinton is a Yale Law School graduate; Senator Obama is a Harvard Law School graduate. (I must acknowledge a bias towards HLS - my class was 1959.) Both of these respected institutions teach their students that words do count and lawyers must be experts at using words.

Clinton's web site (Obama will be discussed in a separate blog( has a summary of her health plan proposal: http://www.hillaryclinton.com/issues/healthcare/summary.aspx. As I read through it (fully recognizing that it is a "summary"), I noted the use of vague terms, weasel words, and few concrete definitions. The summary calls for ". . . affordable, quality health insurance" and reigning "in costs and to insist on value and quality." Clinton calls for a plan which "will secure, simplify and ensure choice in health coverage for all Americans. . . finally addressing the needs of the 47 million uninsured and the tens of millions of workers with coverage who fear they could be one pink slip away from losing their health coverage - with no overall increase in health spending or taxes." Magically, "For those with health insurance, the plan builds on the current system to give businesses and their employees greater choice of health plans - including keeping the one they have - while lowering cost and improving quality".

When I turn to Clinton's "americanhealthchoices.pdf" site, where the resources (savings related to existing spending) to pay for this utopian health care system are described, I find projected savings related to "Reducing Overpayments and New Efficiencies": $10 billion from Phase-outs of Excessive Medicare Overpayments to HMOs and Other Managed Care Plans; $7 billion in savings related to Unnecessary Medicare and Medicaid Spending; $4 billion in savings related to Constraints on Prescription Drug Costs; $35 billion in savings from Modernizing the Health System. I also find a projected $54 billion savings through "Limits on High-Income Tax Breaks". Add these together to get $110 billion which is a relatively small percentage of our $2 trillion plus current expenditure.

The words do not adequately describe the means for accomplishing the needed savings and new revenue sources Clinton's plan requires, nor do they address the practical means of accomplishing her proposed enormous task. Clinton has not just left herself wiggle room, her use of words belies her own belief in her ability to accomplish the health reform which America needs.