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.

Who Will Provide Medical Care In A Disaster?

My wallet contains two unusual cards. One, which bears a picture of me at an earlier stage in my medical career, identifies me as a California Disaster Service Worker. The second, titled "Medical Volunteers for Disaster Response," identifies me as a physician specialising in internal medicine and hematology affiliated with the County of Santa Clara Public Health Department, Office of Disaster Medical Services.

It was in the context of the second card that I recently attended a three hour meeting of the Medical Volunteers. I learned that the system of federally recognized organized medical and public health professionals with which I am affiliated as a "sworn" volunteer is the 9th largest such emergency system in the nation, serves as daily population of about two million, covers more than 1300 square miles which includes 15 municipalities, and is headquartered in Silicon Valley. We are volunteering to respond to natural disasters and emergencies.

Santa Clara County's medical health system includes public and private elements, The County has 3 trauma centers, 11 emergency departments, 12 hospitals, a public health laboratory and disease outbreak teams. There are 12 fire service providers, 7 private ambulance service providers (with far more ambulances than the nearby City/County of San Francisco), and 14 public safety answering points. The medical health system is a major employer, with 1300 emergency medical technicians, 700 paramedics, 50 critical care transport nurses, 40 mobile intensive care nurses and more than 350 medical volunteers.

Medical health resources includes strategically placed chemical packs, elements of the strategic national stockpile, caches of personal protective equipment, stockpiled local pharmaceuticals, a biodetection system, environmental monitoring systems, hospital data systems, and field treatment site trailers. There is the capacity to electronically track patients, which experience in other catastrophes has proved to be essential.

Before an emergency, identification of the critical emergency players, facilities, equipment, resources, and system strengths and weaknesses, is essential. Santa Clara County has stepped up to the plate. In following blogs I will report my impressions of our readiness.

Means Testing For Medicare?

I didn't have to wonder too long why the Sunday, July 20, 2008 New York Times felt so light in weight. It was the trial balloon by Tyler Cowen (professor of economics at George Mason University) at p.4 in the business section.

Cowen focuses on and endorses a proposal by Peter Schuck of Yale Law School to use means testing to reduce the Medicare deficit and reallocate funds to the poor. He argues for tying the size of Medicare benefits to a person's lifetime income, which he describes as ". . . relatively easily measured and hard to game, rather than to one's income or assets in any current year." Cowen pays no attention to the vicissitudes of life (well described by Restoration and later English writers) which demonstrate that past earnings do not guarantee present solvency or a high station.

Cowen implicitly blames those who have worked productively for the high costs of Medicare and gives them no credit for the increased federal, state and local taxes they paid. While it may be politically expedient to point the threatening finger of blame at this group, to save really large sums, why don't he and his colleagues look at cost shifting by employers and insurers to Medicare, the rise of for-profit hospital systems, the failure of Medicare Part D benefits to take advantage of competitive bidding for supplying pharmaceuticals, the inclusion of unscientific and irrational services and systems of care in Medicare, and gaming of Medicare and Medicaid by the states.

Careful public inspection and discussion will deflate this trial balloon. Right now, it seems to be filled with political hot air.

What Are We Doing To Our Kids?

Now that the investment bankers are being granted debt amnesty, the subprime lenders are in the process of being rescued, the bankers are being bailed-out, the Iraq infrastructure is in the process of being rebuilt, the hedge funds allowed to hedge (at whose expense?), Halliburton has been paid-off, the drug companies can sell Medicare Part D drugs without fear of having to negotiate prices as one would expect in a capitalist environment, the elderly are being provided with Medicare insurance, some subprime borrowers are being provided with legitimization of their fraud, Grasso is going to keep his NY Stock Exchange paychecks, American munitions manufacturers continue to prosper from the wars in Afghanistan and Iraq, the HMOs are protected from insolent and uncaring behavior for those they insure through ERISA HMOs and PPOS, we have massively indebted ourselves to the Chinese, and the politicians are pandering to their campaign contributors and respective electorates in the upcoming congressional, presidential election, there's one group that is being ignored.

Kids have no vote and no power as a political bloc. Kids have only parents who are being threatened, worn-down, emotionally and financially destroyed by our combination of inflation, recession and sacrifice of humanity for business efficiency. Kids have schools that are being under-funded, teachers that are disillusioned and worn out, and the havoc of single parent families. Kids have health care that is underfunded, undersupplied and inaccessible. Kids are the real victims of our dysfunctional government, economy and society. But no-one talks about what we are doing to our kids on the morning news of evening comedy shows.

We have, or are in the process of, paying off bankers, the real estate industry, investment houses, the military-industrial complex, business, politicians, the elderly and anyone who has any political leverage, while we disinvest in our kids.

What have we become?

Attend to Patient Information or Get Fined

Those who carry PDAs, cell phones and laptops with unencrypted patient-identifiable information beware.

The Department of Health and Human Services announced today that it has agreed with " . .. Seattle-based Providence Health & Services (Providence) to settle potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules. In the agreement, Providence agrees to pay $100,000 and implement a detailed Corrective Action Plan to ensure that it will appropriately safeguard identifiable electronic patient information against theft or loss." The Resolution Agreement relates to Providence’s loss of electronic backup media and laptop computers containing individually identifiable health information in 2005 and 2006 ( . . . between September 2005 and March 2006, backup tapes, optical disks, and laptops, all containing unencrypted electronic protected health information, were removed from the Providence premises and were left unattended. The media and laptops were subsequently lost or stolen, compromising the protected health information of over 386,000 patients. HHS received over 30 complaints about the stolen tapes and disks, submitted after Providence, pursuant to state notification laws, informed patients of the theft. Providence also reported the stolen media to HHS.)

The Resolution Agreement and Corrective Action Plan can be found on the OCR Web site at http://www.hhs.gov/ocr/privacy/enforcement/.

When the Vultures Circle

Not far from my house is a tree where vultures nest. One evening, my wife and two of our friends counted 42 vultures settling-in for the night. They came in about 90 minutes before sunset, gracefully floating on thermals, heading right into their favorite tree. A neighbor, originally from Brazil, told us that there vultures were held in high regard because of their ecologic role as scavengers.

When I was a hospital medical staff officer, I witnessed a different vulture experience, usually in the intensive care unit (ICU). It typically involved a circle of physicians with mediocre professional skills who took turns consulting on each others' patients. The same physicians gorged themselves on these patients' resources and extended patient stays through unnecessary and inappropriate consultations and tests. The ICU nurses, when asked, would explain that they did not even know which physician was primarily responsible for these patients' care. These nurses complained that when they called these doctors, each would claim only to be a consultant and not primarily responsible for the patients. Even the patients' families could not get a physician to acknowledge primary care responsibility.

While the vultures circling in my neighborhood provide a useful societal service, vultures circling in ICUs not only signify a poor prognosis, but questionable medical competence and ethics. A patient, and patient's family and friends, should demand accountability from each professional with whom there is any contact. . . and should check the bill to determine whether the two minute blow-through visit was billed as a high-priced full complex consultation.

Medicare's Unconvincing Racial Identification System

Normally, I would just have passed it by. The title, "More Accurate Racial and Ethnic Codes for Medicare Administrative Data" in the Spring 2008 Health Care Financing Review isn't exactly compelling.

Eighteen months ago I attended a symposium conducted by experts from Family Tree DNA, a service which matches and tracks mitochondrial and Y chromosome markers for those interested in genetic genealogy. One of the experts spoke about serious flaws in customary forensic identification of individuals' race assignments in criminal proceedings and the availability of technology advanced and convincing new methods.

As I read the Health Care Financing Review article, I noted no proof of the correctness of its claim that the authors' ethnic recoding and reidentification of beneficiaries improved the accuracy of coding for Hispanic and Asian or Pacific Islander beneficiaries. There was no independent technical verification of the validity of the authors' approach using available genetic confirmation. Basically, the authors seem to have claimed victory because their conclusions matched the biases they brought to the project.

This is no trivial issue because the statistical approach adopted by the authors, to "identify health care disparities between Medicare beneficiaries who are White, Black, Hospanic or Asian/Pacific Islander can safely proceed . . .it means it is possible to monitor efforts being made to reduce or eoiminate health care disparities among these groups." In other words, lots of dollars will be allocated differently if the authors' premises and conclusions are accepted.

Is this science or politics? Disease appears to match genetics more closely than loosely identified titles such as "race" or "ethnicity". Let's spend our money on science rather than biased conjecture which may lead to political decisions.

The Most Dangerous Addiction

Don't believe that heroin, cocaine, morphine, methamphetamines and oxycodone are the most dangerous addictions in health care.

The most dangerous addiction is cash flow on which health care systems, insurers, HMOs and providers depend. Improving cash flow induces an endorphin glow; a dimishing cash flow causes cash and credit to become unavailable resulting in acute deprivation symptoms. Analysts devalue health-related stocks and bonds, boards berate executives and their administrations, chief financial officers get fired, providers get paid less with the expectation that they will do more, and health system employees lose their jobs, homes, communities, family health insurance, and social connections. All this without ever smoking, snorting, inhaling or taking a "hit".

As our recession worsens, layoffs will cause loss of health insurance with appropriate medical diagnostic, treatment and pharmaceutical services and products (and leave the former employee with no recourse under ERISA). As employment rolls dwindle and with available global options to save money, employers will change health insurance programs which, in turn, will add higher copayments, restrict benefits, insert more difficult administrative barriers to authorizations and contract with insurers and HMOs which may not have the most qualified physicians, hospitals and health care providers. Providers will find that insurers and HMOs become more difficult to satisfy when claims for payment are made. When a recession is coupled with inflation, a few days' delay in payment to providers may means thousands (or millions) in "float" to payers and wreck providers' cash flows.

Systems which are closely linked to specific manufacturing or service industries may be the most vulnerable to a downturn. HMOs and insurers dependent on stable enrollment will experience the shock of lower membership rolls and cash flows. The impact will be directly felt throughout health care.

See Kaiser Network's article on the vulnerability of UnitedHealth Group which announced its lower profit outlook and said that it will undertake some restructuring at http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=53110

Forest Fires, the Plague & A Hospital ER

The fires which now burn in Northern California bring to mind a time, more than twenty years ago, when it seemed that the entire countryside near Big Sur was in flames. As it turned out, it wasn't the fire that had the potential for creating a disaster. It was a disease which was transmitted because of the fire.

During that fire, animals normally secluded in the forest, desperately sought to escape. They came into contact with humans, and in particular with one person who sought to care for those animals who were injured. That contact created a potentially explosive medical illness.

Hospital emergency rooms were very different than they are today. There was no long wait. Physicians did not "sign out" to the hospital emergency room when they went off-call (many hospital medical staff bylaws specifically prohibited such a practice) and young physicians were eager to develop their practices, and augment their incomes, by providing prompt consultations to emergency department doctors.

The patient who had been in contact with the animals fleeing the fire knew he was very sick, but did not know that he had contracted the plague through his care of injured animals. The doctors who cared for him in the emergency department, and later in the intensive care unit, did not immediately know that they were dealing with a person suffering from one of the most feared diseases in human history. By the time that the patient died, just a few days later, the diagnosis had been established and the patient had been treated with antibiotics which presumably controlled his infectiousness. There was no further spread of the plague that week.

If that person came into a hospital emergency room today, how many hours would he have had to wait to be seen? How many people would he have come into contact with? How seriously would the doctors who saw him have considered his non-specific complaints. If he was uninsured, would he have been deemed sick enough to warrant admission? If he had had insurance, would the insurer have balked at authorizing his admission. Would his illness been promptly and competently treated, as it was, or would overloaded bureaucratic and impersonal health system which can be found in hospital emergency departments in cities throughout the United States, through a combination of system incompetence, lack of concern, overwork and financial overextension have allowed this man's infection to become explosive devastating pneumonic plague?

Is The NY Times Brain Damaged?

The Times ran a multipage article, critical of CT angiography, on Sunday, June 29, 2008. The headnote reads: "CT Scans Give Doctors Financial Incentive, But Medical Benefits Are Unproven." Compare this position with the Times supportive position on computerized health records which also (though one wouldn't know it from reading the Times) have unproven medical benefits.

Where's the Times Public Editor when the right side of its brain doesn't talk to the left side?