But We're Not Greedy

Imagine that President Obama is walking along Chicago's Michigan Avenue and a guy comes up and offers to sell him 75 cents worth of health care for a $1.00. Obama is irate. Look, I'm a Harvard lawyer: what kind of fool do you take me for?

The guy explains, "it's a good deal". He goes on, "I work for an insurer that spends a lot of lobbying money and we support Democratic and Republican Representatives and Senators. We do a lot of investing, financial stuff and manage a lot of money. All we want is to do business as usual. America, it's employers and citizens pay us a dollar, we give 75 cents worth of health care. But we're not greedy - we share some of the remainder with the political parties and legislators, and every one's happy".

Is this imaginary? Is everyone really happy?

Same Old --- Same Old

I have been listening and looking for substantive improvements in our health care system coming from Washington, but none have been forthcoming. Lots of talk from President Obama about cutting the costs of health care (health care is approaching 20% of the GDP because our economy stinks - it's the old specious "denominator" problem). Lots of speculation in the New York Times and elsewhere about how insurers, those "guardians of all improvement in the health care system," will be protected from competition by the government, other insurers, and providers. Meanwhile, the focus on profits for insurers and cutting the cost of services for the public makes me wonder who will be the victims.

Will it be children, who have no voting rights and therefore only very limited political power whom we have proportionately decapitalized? Will it be the elderly, who do vote, but with a cost-benefit analysis approach don't add much to the GDP and make it hard for economists to justify spending a lot of money for each year of life which is added (or to relieve pain and suffering which is difficult to value). Will it be the unemployed and uninsured who will simply be a drain on the Treasury, and from one party's political perspective, may not be worthy enough to justify health care expenditures for them. Will it be the working middle class, who seem no longer important enough politically to justify their getting the "middle class tax break" that Obama promised pre-election? Will it be armed forces personnel, who, once political furor over Iraq simmers down, will nurse their injuries in understaffed and underfunded back wards of VA and inaccessible facilities? Will it be the undocumented immigrants who now fill our emergency departments? Will it be the prisoners in our federal/state/local prisons and jails?

Folks, competent health care will be available to the same people who now get what they want: individuals who are wealthy, who are well-connected politically, make substantial contributions (directly or through PACS or otherwise) to politically powerful people/organizations and their connections and employ lobbyists who have access to the politically powerful and their rule makers. (Google the search terms "political donation insurer".) And, like AIG and the financial sector, they will take care of each other. And the children, elderly, working middle class, injured and uninjured veterans, immigrants and prisoners - "sorry - but we have to cut costs."

And if you (or a member of your family) are really sick and need expensive testing, treatment, care, pharmaceuticals, and technology, where do you think you or your family member will be prioritized in cutting health care costs?

Ethics Are Even More Relevant Today

If we had agreement on political contribution ethical standards (i.e., $$$ flowing from AIG to major political figures), would there be an issue today concerning AIG's $180 million bonuses to those who wrecked their company and severely damaged the international economy?

If we had standards of ethical conduct for those doing business in the financial industry, such as Madoff and Stanford, would America be in a depression?

If we had standards of ethical employer conduct, would the SEIU be at war with the union representing its own workers?

If we develop enforceable consensus concerning the ethical framework for health care reform before plunging into unguided action, will we have a more efficient, better quality, more accessible and more democratic health care system which does not bankrupt the country?

What prevents us from a national discussion of health care ethics and use an ethical structure as the framework for health care reform?

Genetics, Population-Based Risk Studies & Public Access

Years ago, while performing 5-minute employment-related physical exams for a nursing home's employees, I violated the guidelines published in an insurance company's sponsored meta-analysis of the value of various physical examination steps. My mistake in examining the 35 mostly female workers was that I actually performed brief physical exams which uncovered a thyroid cancer in a 16 year-old (subsequently cured by surgery), an abdominal mass in a 16 year (a large teratoma subsequently successfully removed) and a cancerous breast lump in a 40-ish administrator.

According to the meta-analysis, I wasted my time checking the thyroid, abdomen, breast and other organs in these apparently healthy, uncomplaining, low-risk women.

Population based risk studies cannot predict the particular person who will have a thyroid cancer, teratoma or breast cancer. They predict that a certain percentage of the population will or will not get sick, not the names of those individuals. Risk-analysis studies should never be relied upon by a payer, physician or other provider as conclusively determining what needs to be done for each patient.

The 5 minutes I spent for each of the women described above yielded cures of serious diseases and saved the nursing home and its health insurers significant sums as patients were cured in an asymptomatic early stage of their diseases.

For the last 3 days, at my own expense, I have been in Houston, attending a genetic genealogy symposium held by Family Tree DNA (I have no financial interest in Family Tree DNA). Among the technical subjects, there was significant discussion of steps taken by various state governments, under the urging of "doyens of proper practice", against 2 companies which market "Direct to Consumer" genetic testing and provide information about population-based risks. Some of the experts have even leveled their artillery at genetic genealogy (which in my case, has restored a broken link to a family I would never have otherwise found).

Genetic genealogy is no threat to consumers. Participation is voluntary. If one does submit a specimen for analysis and is disappointed with the results (i.e., finding out that he is not related to Gates or Buffett, but might have several horse thieves in her family), it's not likely that the person will be at significant physical, mental or financial risk. Genetic genealogy links traditional genealogy research techniques to inferences about ancestral genetics. An enormous anthropological study, using similar techniques, is sponsored by The National Geographic Society and has been well supported by the American public. Rather than throw-up roadblocks to progress, government should provide standards which each laboratory performing genetic tests should meet and supervision by qualified inspectors to be certain that standards are met.

At the meeting, I heard reports of criticism of companies performing "screening" genetic tests to assess population-based risk of disease. Several of these companies employ genetic counselors (disclaimer: a member of my family works for one of the companies, but has not had any input into this blog) to provide sophisticated information to their clients. And at least one provides training for physicians interested in this area so they can develop expertise and provide medical advice and care to their patients.

The opposition to allowing individuals to spend their money to learn about population-based risk is puzzling. Dismissive statements such as "instead of spending money on genetic tests, they should stop smoking, reduce their alcohol intake, exercise and eat more vegetables" reflect arrogance. Political involvement in this issue may be more focused on raising political contributions, than in contributing to the knowledge, health and life enjoyment of Americans. Americans should have an unfettered right to purchase information and knowledge which may stimulate them to make changes in their lives affecting their health. And they should have the right to take their information to the physician of their choice to seek consultation and advice.

Since the Middle Ages, science and truth and knowledge dissemination have driven societal development and progress. When government prohibits access to information and advances in information technology, it is doing the nation no service. Let's stop the paternalistic nonsense of "our government will tell you what's good for you and what you need to know." If individuals want access to genetic risk-based information, they should be able to have it.

In these days of evidence-based medicine, rather than accept the criticism of the doyens, a study should determine whether the availability and understanding of genetic information about population risks changes people's behavior, reduces their risks and reduces the nation's cost of health care. Based on my participation as a fellow of the Health Research Council of the City of New York in the early 1960s (which is when dietary saturated fat intake dropped dramatically for the first time), I predict it will.

Five Easy Questions -

A few questions about "universal health care" in the United States.
1. What does "universal" mean?
2. Does "universal" define the scope of services, the scope of conditions for which care is to be available, the scope of the population being served, the scope of payment, or the entire spectrum from prevention through diagnosis, testing and treatment? Will non-legal residents receive health coverage? Will tourist visitors receive health coverage? Will coverage be made available to individuals who have "green" cards? Will coverage be available to those who do not cooperate in their own care and demand one provider after another, one test after another, and one treatment after another?
3. What does "health care" mean? Does it include "prevention"? Does it include care which diagnoses and treats conditions and diseases which shorten life expectancy? Does it include care for conditions which make life miserable, as through mental illness, addiction, pain, cosmetic defects, conditions associated with lifestyle choices, malnutrition due to poverty or neglect, obesity, environmentally transmitted (or caused) disease? Does it include contraception, abortion, liver transplants for alcoholics, lung transplants for smokers, pancreas and kidney transplants for uncontrolled diabetics, and heart transplants for those who refused to take cholesterol-lowering drugs? Will prayer be covered as a therapeutic modality? Will unproven remedies be covered? Will prescription medications be fully covered? Will high technology artificial limbs and prosthetics be covered? Will special educational services be covered? Will taxicab rides, provided to beneficiaries to get them to a medical center, be covered?
4. What are the limits to "universal" and to "health care"? What decision making process will be used to allocate resources?
5. Upon what ethical principles will health care be provided, denied and decisions made?

The Workhorse Group - A Club For Market Allocators?

While there's lots of captivating bad news, television networks are highlighting Friday the 13th-style horror movies' commercials, and the messages from stock brokers and advisory services are rightfully producing panic among those impacted, a series of different recent events has me worried.

On February 20, 2009, the New York Times described "behind closed doors" talks involving major health care players, lobbyists, unions, national organizations, financial interests, and staff of Senator Ted Kennedy. From the NY Times information, it seems that requiring all individuals to purchase health insurance is a major issue of discussion and various options for funding are on the table including individual responsibility, employer contributions, and public programs.

My concern is that under cover of cooperation with Senator Kennedy, and possibly free from the scrutiny of anti-trust enforcers, monied interests are dividing up the health care marketplace and lining up to offer political endorsement (and, presumably dollars), to those who support their positions.

Mr. Kennedy - open the doors now. An industry approaching $3 trillion, requires fresh air and sunlight, not the clubby atmosphere of restricted membership, drawn curtains, winks and nods.

Part D Insurer Passive-Aggressive Behavior?

Imagine this. On your way to an important appointment. you drive down a busy 40 mile per hour street behind a car moving no faster than 27 mph. You can't pass. There's no way to get around this driver. And then the light changes and that car drives right through the changing light, giving you the "finger", leaving you late, stopped and angry.

A psychoanalyst friend uses this scenario to illustrate passive aggressive behavior. The driver ahead of you deliberately and consciously roadblocked and provoked you, and then sped through the light.

My wife and I recently encountered a passive-aggressive situation with respect to a Medicare Part D drug. In the late Fall of 2008 we were reminded by our Part D insurer that we didn't have to do anything to renew for 2009. Late in December, just before the time had expired to renew, the insurer sent us its complex revised formulary which tripled our copayment for Zetia by raising the copayment and moving Zetia into a higher tier and threatened to non-renew our Zetia prescriptions. My wife made a number of calls to the "customer service" desks at that insurer, was given different stories by each of the persons she talked with, and was sent numerous differing forms to "appeal" the tripled Zetia copayment and non-renewal threat. Our physician sent a letter to the insurer. The company responded, indicating that it would provide us with Zetia for the next 20 years and then charged us the full augmented copay (which, having no other choice, we paid), as if our appeal had been denied.

More days of calling brought conflicting responses and forms until my wife finally learned that the company had agreed to grandfather us to the extent that it would provide us with Zetia, but had not considered restoring our copayment to what it had been before January 1, 2009 leaving us with the prospect of paying about $2000 a year for this one, of many, prescriptions. However, after almost two months of frequent calling, for the first time the company acknowledged that our physician could submit an appeal letter to roll-back the copayment.

Since I spent years negotiating contracts with HMO, PPO and other insurers, I am familiar with their tactics. The confusing, conflicting and opaque behavior of our Part D insurer was neither the result of incompetence nor accident. It was a calculated stall to block, or at least discourage, customers from getting the drugs they need. The insurer's calculation was for its financial benefit: mislead, block, delay and use secret administrative policies, not clearly disclosed to the Medicare customers brought to it under Part D, for its own profit.

When the driver ahead of you is passive-aggressive, you may become angry, but for the mature driver, there is no lasting injury. When Part D pharmaceutical insurers' policies are passive aggressive, mature Medicare beneficiaries will die.

I hope that the Obama administration will not fill health care reform posts with people (including board members) connected with health/pharmaceutical insurer policies of secret administrative regulations, deliberate misleading of Part D beneficiaries, blocking and stalling the provision of needed drugs, and other obstructive health insurer profit-enhancing behavior. Persistence of these policies will generate public frustration and anger. And people will die.