Obama's Quest For $634 Billion

WASHINGTON (Reuters) Feb 24 - Health spending will hit $2.5 trillion this year, devouring 17.6% of the economy, as the White House and Congress consider major changes to the health care system, U.S. government economists said on Tuesday.

Reuters reported a forecast by The Centers for Medicare and Medicaid Services predicting an increase in health care's percentage of the gross domestic product by one percentage point (to 17.6% of the gross domestic product) in 2009 as compared with 2008.

For my earlier discussion of this issue see the "Avalanche" blog: http://www.blogger.com/posts.g?blogID=1547787506785837911&searchType=ALL&txtKeywords=&label=Health+Care+Inflation.


Reuters quoted CMS economist Christopher Truffer: "We project that the health share of the economy will increase steadily through 2018." The increase in health care percent of the gross domestic product not only reflects the subject of my earlier analysis, but also increased costs of technology, population growth, an aging population, pent-up unmet demand (i.e., from those receiving insurance for the first time (i.e., through Medicaid) and immigrants who may not have had access to advanced health care before arriving in the U.S.), time spent with patients, prescription drug costs, and the failure of providers to provide efficient systems of care (as patients move into hospital emergency departments where extensive testing and high costs of care waste enormous financial resources.

If Obama's rationalization of health care reflects the excesses and lack of corporate responsibility that we have already seen in the financial industry, we will have a big, expensive, inefficient health care system which increasingly fails to provide care as predatory unethical and wasteful behavior flourishes. Even if Obama gets the $634B over 10 years for health care that he seeks, without a program grounded on an ethical framework which reflects American consensus, health care will not improve. We will move to a 20% of gross domestic product health care system with lots of money for corporate entities and no significant benefit for our citizens.

Juan Enriquez: Beyond the crisis, mindboggling science and the arrival of Homo evolutis

Science and the health system to come. A mind-opening discussion which is worth listening-to and thinking-about. Enjoy after clicking on the title above.

Facebook - A Lesson For Electronic Medical Records Enthusiasts

Who owns your health data? Your doctor, who created the written record from information that you, labs, radiologic services, other physicians, hospitals and other resources supplied, believes that she owns the record. When your doctor reaches retirement, she will "sell" her practice to another physician who will receive and hold those records. If your doctor doesn't have some rights to those medical records, she won't have much to sell and her retirement funding may be scuttled by her inability to sell her practice to a successor.

If medical records become relegated to an electronic database, who owns the records? Is it the patient, insurers, the owner of the network over which the records are transmitted, the owner of the hard drive or server-farm on which the records are stored, the medical practice, some hacker (perhaps in Russia or China), the federal government, Microsoft, or some other entity? Or does this simply remain an issue between you and your doc?

That brings us to Facebook which attempted to impose its own interpretation of ownership of the material within its domain. This is the rule that Facebook unilaterally published, which created a storm among its customers:

"You hereby grant Facebook an irrevocable, perpetual, non-exclusive, transferable, fully paid, worldwide license (with the right to sublicense) to (a) use, copy, publish, stream, store, retain, publicly perform or display, transmit, scan, reformat, modify, edit, frame, translate, excerpt, adapt, create derivative works and distribute (through multiple tiers), any User Content you (i) Post on or in connection with the Facebook Service or the promotion thereof subject only to your privacy settings or (ii) enable a user to Post, including by offering a Share Link on your website and (b) to use your name, likeness and image for any purpose, including commercial or advertising, each of (a) and (b) on or in connection with the Facebook Service or the promotion thereof." If you click the title above, you will have a link to the Facebook operation's web page which documents the results of its unpopular attempt to appropriate its customers property, including copyright rights.

Now, any politician who believes that Americans will be happy if their private personal health information is appropriated for the purposes of insurers, the federal government, Microsoft, hackers or a host of others who have financial interests at stake just doesn't get it. Clicking the title (above) will bring you to the Facebook web page which will illuminate everything.

If Obama doesn't pay attention to the Facebook storm, he won't understand the potential for disaster in the appropriation of individuals' private medical histories by the health care government/industrial complex and its financial industry allies.

If You Are (Or Were) A CVS Customer . . . .

Unsecured industrial trash containers outside certain stores, is no place to dispose of privacy-protected patient information, as CVS and CVS Caremark, Corp. (the parent chain) have learned. In coordinated investigations and actions, the FTC and Office of Civil Rights found that "CVS failed to implement adequate policies and procedures to appropriately safeguard patient information during the disposal process; and CVS failed to adequately train employees on how to dispose of such information properly". CVS and CVS Caremark signed resolution agreements with the FTC and HHS involving $2.25 million dollar resolution amounts and commitments by CVS and CVS Caremark.

Clicking on the title above will bring up the HHS Resolution Agreement and Corrective Action Plan. OCR's new FAQs concerning disposal of protected health information can be found at http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/disposalfaqs.pdf while information about the FTC Consent Order agreement can be found at www.ftc.gov.

Response To Concierge Blog

I received a response to my blog dealing with Concierge Practice, from an unnamed physician. It is lengthy, but worth reading. The practice described is a limited sample.

"As an experienced family practice and ER physician who opted out of the traditional practice model, it always amazes me when colleagues attack the practice model. Granted, it is not a model that everyone should adapt or that everyone needs or even wants, but for those who do desire such a service or who may really have a need for such a service, it is a very reasonable healthcare model. There is always the argument that it steals providers away from the general population, but for some providers it keeps them in the game, when they would have otherwise finally opted out of medicine altogether. Additionally, many providers dream of doing benevolence work like Doctors Without Borders, or as in my case, seeing subsectors of disadvantaged patients like kids with disabilities. These kids take a long time to see in the office, sometimes an hour or more. Busy practices do not want to care for them, because they disrupt the flow...and the revenue stream. Since I provide services to a much smaller number of clients, I can take the time to patiently wait to gain the confidence of a flapping child with autism who is melting down in my office and then the extra time it takes to work with him or her just to get an appropriate assessment. Better yet, I can keep him or her in an environment where the child won't melt down, at home, where the child's routine is not so significantly disrupted. Yes, I do charge my clients a high dollar fee, but at the other end of the spectrum, that single mother of three, one of whom has severe disabilities, gets care for not only her children, but for herself, in spite of the fact that she has no ability to pay. I don't ask her to pay, because I don't have to do so. One of my high paying clients paid for convenience and in so doing allowed me the ability to take care of someone who was in a less fortunate economic condition without having to forego paying my own bills. There is a place for such practices. I provide a service that clients on both ends of the financial spectrum appreciate. Although on the surface it seems like an easy ride for lazy, greedy physicians to some, it will not threaten the current healthcare system, because when most physicians realize the real effort and commitment that it does take to do it well, they quickly head back to their own practices, saying, 'No Thank You! That is too much work! I'm not willing to give up that much of myself.' Concierge medicine is a wonderful practice model. I love what I do, but it does have its trade-offs. My patients are happy to pay for the extra "service," just as they are happy to pay for the extra services they get on first class plane flights or private jets and in six star hotels, as opposed to the Holiday Inn. You get a comfortable bed and a good nights sleep at both the Waldorf Astoria and the Holiday Inn, but you pay more at the Waldorf, not because of the bed, but because of the extra fancy little services. There is a place for both the Waldorf and the Holiday Inn. I don't believe either is threatened by the other. So should be the case with concierge medicine and other models. They are just different practice models serving different client populations with different wants and needs. There is no reason we should have any less flexibility in medicine. Additionally, just as the Waldorf makes contributions to the well-being of the community, concierge physicians give themselves the freedom to be benevolent, freeing themselves up to be able to do more. Call me naive, but I would like to believe that most physicians did go into medicine, because of their desire to help others, so I believe that most will give back to the communities that they serve in, if given the opportunity to do so. At least for me, concierge medicine provides me a viable opportunity to do so in a much larger, more sensible way. Besides, concierge medicine has always been there for those who could afford it. We have just formalized it, giving it a title and raising its visibility to the general public. People who have money at their disposal will always find ways to use it to get the extra personalized services that they desire and frequently need because of the lines of work they are in or the positions they hold in society. Many will find it because they have medical and/or social needs above and beyond what the standard system can accommodate. I see it as an adjunct to the traditional care models. I believe it can even serve to relieve the stress on overburdened practices, who can refer time-intensive patients over to concierge providers who can provide them with the extra time that they need, want, and absolutely require in order for them to get good quality care. It is one of many niches...and there is room for all."

Problems Ahead For Concierge Medicine?

Concierge practices may be structured differently, but the fundamental illusion conveyed is that the patient will get special, convenient, extra, perhaps even better care, than the person who sees his or her "ordinary" physician. At one of my Thursday physician lunches, a specialty physician regaled colleagues with the story of a concierge physician who called to demand an immediate appointment for one of his patients. The concierge physician's patient got the next available slot for a consultation, just as any other patient would have.

On January 20, 2009. the Maryland Insurance Commissioner announced a report that some of the concierge arrangements cross the line of providing insurance and suggested that physicians seeking a concierge practice seek "appropriate professional and legal advice in this area." The Maryland Insurance Administration raised caution flags with respect to two types of arrangements, the "Annual Evaluation Model and Bundled Fee-For-Service Models." It did not elaborate on balance billing and medical ethical issues in the context of these practices.

Before signing up as a patient in a concierge practice, patients should consider whether they should forgo being treated by a busy energetic experienced "ordinary" physician whose practice generates sufficient income independent of practice gimmicks.

A New SAT Question

What is the similarity between between Ariel money manager J. Ezra Merkin (who The NY Times 2/14/2009 p. B3)invested $2 billion of his clients' money with Madoff) and a subsidiary of Compushare which sells high-end software in the health care field (p. A13)?

Merkin received some of his telephone advice directly from an "Imprisoned Felon," Victor Teicher, whose federal securities fraud felony landed him in a New Jersey prison.

Covisint, the Compushare subsidiary, is paying $100,000 a year plus commissions, to felon and ". . . former Detroit mayor Kwame M. Kilpatrick . . ." because he is "uniquely qualified" to sell high-tech services in the health care field.

Have you any unease about the safety and integrity of your personal medical information? Or about the types of operators who - attracted to electronic medical records services, as vultures are to decaying carcasses - look upon the federal governments' willingness to pour resources into electronic medical records as an invitation to feast?

Is the Obama administration oversight of electronic medical records to be like the Bush administration oversight of Halliburton in Iraq?

Today's Lunch

Today's lunch, hosted by a drug company representative concerned about staying employed in this era of company consolidation with layoffs, was notable. A recently retired superb oncologist, with impeccable judgment, patient relationships, integrity, knowledge and skills told us that he had left practice because in his last year he lost $60,000 and could no longer afford to practice. Another excellent experienced highly competent physician, who needs to find new office space, observed that space comparable to his current $3 thousand a month space would cost him $8 thousand a month which he cannot afford.

These are solo physicians who have taken superb care of patients year in and year out. The corporatization of competing (but not equal quality) medical practice, and the inability of these physicians to negotiate successfully and competitively with payers and space/service providers because they are not part of a muscular network, has put them at risk of being forced out of practice.

The emphasis on computerized medical records is misplaced. Why throw high-quality current practicing doctors away while chasing the Computerized Medical Record windmill?

HHS OCR Posts New Website for Health Information Privacy

"The Department of Health and Human Services, Office for Civil Rights has posted its new Web site. The health information privacy (HIP) pages have been extensively revised to improve organization and ease of use for consumers, covered entities and others seeking reliable advice on the HIPAA Privacy Rule and the Patient Safety Rule.

"The Web site contains significant new content including
For Consumers pages (with new information on):
Medical Records
Employers and Health Information in the Workplace
Personal Representatives
Family Members and Friends
Court Orders and Subpoenas
Notice of Privacy Practices
Privacy Rule home page—rulemaking timeline
Enforcement Rule home page—rulemaking timeline
Emergency Preparedness home page
Genetic Information Nondiscrimination Act page
Special Topics home page
Before you File a HIP Complaint
Patient Safety Rule home page
Patient Safety Statute home page
Patient Safety Enforcement Activities and Results home page"

You can reach the new health information privacy web pages at http://www.hhs.gov/ocr/privacy/index.html

Physicians As Data Entry Clerks?

Brent Gendleman (president and CE of a software consulting and development company) has written a spirited, apparently self serving, and uninformative letter to the editor of the NY Times (02/09/09 p. A20) supporting electronic medical records. A notch up is Richard's Rockefeller's letter in which he worries about indecipherable handwriting and articulates something that physicians know: "Competing insurers will always find ways to discover patients' health problems and exclude them from coverage." A.G. Krohn, a doctor, writes that office visit documentation time exceeds time examining patients. John J. Frey III (professor of family medicine) demands interoperability rather than Babel. Matthew D. Heller (rheumatology physician) observes that electronic systems spew out useless boiler plate. And Mark Merritt (president and CE of the Pharmaceutical Care Management Association) worries about the risk of a privacy proposal exposing users of electronic records to litigation and red tape.

My observation is that some physicians (perhaps they are "shy") spend more visit time looking at the monitor and interacting with a computer system that they do speaking with and actually examining a patient. You can't find breast or thyroid cancer, or hear a carotid bruit, or pick-up on a patient's depression, when your focus is having an electronic record which meets bureaucrats' needs rather than spending the time talking with and examining your patient.

My practice was, at the end of an office visit, to take about 90 seconds to dictate (for transcription) a complete record of the visit in front of the patient (often in the presence of the person accompanying the patient). This provided all of the information (history, physical, lab, diagnosis and plan) I had in a legible format, gave the patient a chance to hear what I thought, make comments to me or correct my mistakes, and promoted a trusting relationship in which the patient had all relevant information when he or she left. Years later, physicians tell me that those complete paper records contain the details that their computerized systems lack. Today's sophisticated computer voice recognition systems could readily provide hard copy from dictated records and if demanded by the bureaucrats, an electronic accessible record.

Is the use of highly educated and skilled physicians as data entry clerks sensible?

An Avalanche Starts Quietly

Unemployment is up as full-time workers lose their jobs. Unreported unemployment involves workers who, a year ago, had full time jobs but now may be only working two-thirds or half time. And then there are the unemployed who used to make do by occasional agency or contract work but no longer can find any meaningful income. According to the Morningstar video I watched this morning, "Unpacking the Unemployment Numbers," we are not yet at the bottom of our national financial crisis. So what does all of this have to do with our health care system?

Those who are unemployed usually lose their health insurance (while they may have Cobra guarantees of the capacity to extend their former employment health insurance, without income they cannot afford expensive monthly payments). Minor illnesses don't require medical care. Major illnesses, injuries, and pregnancy require expensive professional services. State Medicaid programs are broke and dysfunctional. Lower employment means lower contributions to the Medicare fund which, a year ago, was predicted to be in precarious condition in 2019.

The only bright spot in the nation's employment picture is health care. However, not-for-profit institutions (many of which have no access to the financial market in this depression and if they did, would have to pay high rates of interest) do not have the capacity to subsidize health care for all of America. For-profit, investor-owned institutions are structured to generate profits, not losses. In short, we are in a period of diminishing gross domestic product coupled with stable or increasing demand for health services.

Expect your newspapers and television reports to headline health care inflation since the denominator (gross domestic product) will be smaller and the numerator (total health care costs) will be flat or increased. Listen for dire predictions of Medicare insolvency as the Medicare tax yields less revenue and the aging population requires increasing services. Watch and listen for politicians proclaiming doom and gloom for a national health care system based on erroneous analyses. It's quiet now, but it's coming.

Costco, Kashi & Salmonella Typhimurium

A safe food supply is an essential part of our healthcare system. Salmonella typhimurium must not be in our food because it can cause sickness, and even death.

After reviewing the US government CDC site, in my pantry I found a box of Kashi chewy bars purchased from Costco, some with with the product codes listed in the recall notice and some which were OK. By clicking the widget below, you can go to the CDC site yourself and do your own check for various food manufacturers' and distributors' products. Quick tip - look for the product bar code on the package you have and then check that against manufacturers' or distributors' recall notices. Discard or return a listed recalled product, as I will do today when the box of Kashi bars goes back to Costco.

The CDC site has a more extensive recall list than your local newspaper is likely to have.

It's the Coverup, Stupid

What better time to surface a story that HHS Secretary-nominee Daschle, who apparently had suspicions that he had underpaid his U.S. taxes back in June of 2008, (he didn't pay $128,000 in taxes on a car and driver), than on Saturday of Superbowl Sunday weekend, when America was preoccupied by a circus? Apparently, Obama's vetting process didn't find the story on its own and Daschle didn't volunteer the information until recently. And the malarky about Daschle having to wait almost 7 months to get an opinion from his accountant seems contrived and convenient, rather than forthright and truthful. (Read more at today's NY Times, pages A1 and 11.)

Federal prosecutors love coverups - that's what put Martha Stewart in jail. While Daschle's coverup doesn't rise to the level of a federal criminal offense, the original failure to pay the taxes the rest of America's citizens pay, compounded by the coverup, raises ethical questions which should disqualify Daschle from being Secretary of HHS, overseeing a $3 trillion dollar sector of our economy.

Obama promised transparency. This smells more like an Illinois-style political coverup.