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.