The Appearance of Impropriety

Page 1 of The New York Times (July 30, 2009) describes the river of money flowing, in part, to the Democratic Senatorial Campaign Committee ($500,000), individual candidates ($120,000, and the Democratic Congressional Campaign Committee (House of Representatives) ($800,000+). The sources can be traced to McAllen Texas and the funds were traced by the Times to entities or individuals connected, in one way or another, to Doctors Hospital. (See my blog from 7/14/2009 with its link to the New Yorker article on McAllen Texas' health care costs.)

At a time when President Obama proclaims that his party's health care reform will drive down health care costs and prevent health care inflation, the Democratic Party seems blissfully unaware that the party and its members have provided American citizens with an appearance of impropriety which gives the lie to political rhetoric from Obama, Pelosi and Reid. Our health care system is being sold, without public benefit, to self-serving bidders while Democratic and Republican politicians and their parties reap the economic rewards. All of this while American adults' and childrens' health interests are being violated.

The public is silent. It is not apathetic, and one can readily sense frustration and anger bubbling below the surface.

Ethics, Quality, Compassion

I listened carefully to President Obama's AARP televised and internet-carried conference On July 29, 2009. I heard nothing about the ethical construct for health reform. I heard nothing about health care quality. I heard nothing about assuring Americans that there would be competent qualified physicians available to provide the care that is being promised to them. I find myself more and more concerned that the only subject for Obama and Congress seems to be cutting health care cost inflation and saving money.

I have proposed changes to the health system in earlier blogs. Others have proposed different changes. But the only change that seems to be in the wind is that insurers and pharmaceutical companies' revenues and profits will be protected, with no apparent concern for the quality and ethics for the services they provide.

Years ago, one of my patients with advanced metastatic breast cancer was in the Oncology Unit of a local hospital with a fractured hip. She was in agony and her quality of life was poor, but could have been helped by appropriate orthopedic surgery. MediCal (California's Medicaid) refused, saying that the expense was not justified by the patient's poor prognosis. I called the MediCal authorization number and asked Medical's "authorizer" for the address of MediCal's office. She asked why I wanted to know. I told her that it was because I was going to put the patient in an ambulance and send her to their office for care, because I couldn't take care of her under the circumstances they dictated. After a few moments of silence, I received the authorization. The patient had surgery by a competent and compassionate orthopedic surgeon, went home without devastating hip pain and died several months later appreciative that her pain had been treated, her ability to walk restored, and she could be at home with her family.

I have seen the value of ethical commitment, concern about the quality of care that patients receive and compassion. It is unfortunate that Congress does not address these issues. The Administration and Congress just don't have the words to discuss ethics, quality of medical care, and compassion.

It's The Money, Stupid!

John Roach, the late academic political scientist, said it succinctly: no-one can compromise on matters of principle. We fought the American Civil War, incurring massive losses of life, because neither side could compromise its principles. Some pro-life partisans are in prison for life, because they followed their principles and murdered physicians who performed abortions.

It's not matters of principle which shapes the health care reform debate, it's political money.

Do politicians have commitments to principle? When there is a hot contentious issue with enormous public interest, such as health care reform, politicians can play one side against the other and cash in through political contributions and other financial support. There is no issue of principle: there is only the issue of price. The more contentious the issue, the longer the process, the more money key politicians can garner for their coffers. It's not a party matter, it's money. It's not constituent interest, it's money. It's not principles, it's money. It's not ethics, it's money. It's not doing the right thing for the public, it's money in the treasuries of well-positioned political figures.

$127 million in lobbying by the health sector, which was well-represented in Senator Kennedy's closed office meetings, in the first quarter of 2009 is no small change. Senator Baucus brought in $3 million in the 5-year period ending in 2008 and according to the Kaiser Health News (click the blog title for the link) big contributors included major pharmaceutical manufacturers, insurers and a major pharmaceutical executive.

As you watch the political maneuvering, remember, it's not health care that key people in Congress worry about, it's their economic status and political bankroll. The issue isn't "where's the beef," its "where's the money"?

Senate's HELP Bill Helpful?

A week ago, I posted a link to the Senate's Health, Education, Labor and Pensions Committee's "Affordable Health Choices Act" narrative with my statement that I would comment on it after a chance to review the long document. Today, President Obama noted that the Senate Finance Committee has not yet issued its proposal (which will probably deal with Medicare and Medicaid spending or savings), which is no small matter, because the two bills will have to be combined before the Senate votes on the penultimate bill (the conference committee opus will presumably be the ultimate bill). So, what you read in the Affordable Health Choices Act is not predictive of the substance of the Senate bill. But it's worth comment anyway.

The bill promises insurance market reforms. Since, under pressure from national employers and insurers, a game that the states and insurance industry has played has been insurer incorporation and policy-writing in states with employer-favorable insurance laws. However, some states have larded insurance laws with requirements for specific services demanded by provider, and sometimes patient, pressure groups. I wonder whether there will be federal licensing/certification of all health insurers in the United States which intend to write insurance under health reform legislation, and whether the federal government will usurp (a fighting word for "preempt" in this case) state health care insurance regulatory authorities. If so, there will be significant fight-back from the entrenched insurance regulatory interests, and their political and financial buddies, in all 50 states (except, perhaps, California which is so dysfunctional it might not even notice).

The bill seeks to assume that health insurers engage, with the federal government, employers and the public, in "the collaborative articulation of shared purposes" (a Harvard Law School phrase favored by the late professor Lon Fuller). Again, with my Brooklyn upbringing, I go back to the concept that where there's a lot of money to be divided up, expect the insurers to find techniques and devices to maximize their revenues and reduce their exposures to risks. In the 39 years that I have focused on health insurance, HMOs and other means of financing health care, I have never known an insurer to be particularly interested in anything other than its self-interest. I see no reason to believe that President Obama can change this perspective, reduce health insurers' greed, self-serving behavior and indifference to the suffering caused by their business plans, and control the inflationary pressure on health care costs that they generate.

Subtitle B, "Available Coverage for All Americans" will shunt many "health care" dollars into States' Affordable Health Benefit Gateways. Dollars that should be used to purchase health care will be sucked into bureaucratic byways, never to be seen again or accounted-for though government bean-counters will create expensive paper trail requirements. Instead of insurers getting their 25% overhead, the bureaucracy will share a chunk of that revenue. Where's the efficiency that President Obama promised?

Subtitle C, "Affordable Coverage for All Americans" promises subsidies in the form of a yet-to-be-defined "credit" system. There is a geographic adjustment provision, which if past experience is any guide, will favor southeast states (which will salve their Congresspeople's political wounds and give them something to point to in the next election).

Subtitle D speaks of "Shared Responsibility for Health Care" but only deals with shared responsibility for paying for someone else's alcoholism, smoking, drug use, lack of exercise, dangerous driving practices, poor eating habits, and understated but very real toxic industrial exposures.

Subtitle H deals with "Community Living Assistance Services and Supports." While this may be a laudable goal, should it come from the national health budget? Is it truly health care?

I have only dealt with subtitles of Title I. There's lots more, and I suggest that my readers look at this material critically. What is proposed is a mouse built by a committee. What we will get is an voracious uncontrollable elephant which will leave no grass standing in the health care arena.

Our Health System - A Zero Sum Game?

"Utilitarian Philosopher" Peter Singer, who wrote "Why We Must Ration Health Care" in The New York Times Magazine, July 19, 2009 approaches several health care ethical issues. He starts with a traditional economist's view, observing that health care, a scarce resource, is to be rationed. Moving through examples of structured (i.e., Britain), unstructured (the American uninsured), and structured but not acknowledged publicly (American government), existing rationing systems, he notes several ethical issues inherent in each of these systems and suggests approaches to resolution.

Underlying Singer's observations is, what I interpret as, his belief that health care is a zero sum game. Reminiscent of Senator Ted Kennedy's 1960's physician payment proposals, a budget basket is established: those who qualify for allocation priorities leave less less for later claimants. As I have argued in many blogs, payment to insurers for 25% administrative overhead claims leaves significantly less in their treasuries to actually buy health care services and products.

But, as Singer recognizes, the problem is defensibly defining who is worthy, not in the Saturday-Night-Live sense, but in the sense of identifying humanitarian and socially beneficial criteria for worthiness. He and we run into the application of population statistics to individuals who may be cut-off from palliative or curative treatment because population statistics indicate that they will not live long enough, or well-enough, to justify spending scarce resources on them and thus depriving more "worthy" people of care. This is another form of rationing.

In my practice of hematology, I learned that I could not predict who would live and who would die, who would have lives incorporating many good days, and who would have lives focused on suffering. I could not tell whether my patient, riddled with cancer, would outlive his young wife who brought him to my office (he did). I could not predict that the sixteen year old would receive a remarkable new experimental treatment called kidney transplantation, and outlive many who had more mundane and less threatening illnesses. In short, I could not apply population statistics to my patients and I believe that health reform based upon the principle of such application is fraught with hazard and stinks of charlatanism. I worry that the zero sum game philosophy will yield tragic results.

If you want to know what Singer proposes, read his Times article. Your time will be well-spent.

Health Reform Legislation Proposal

Click the title above for a direct link to the Democratic summary of proposed health care reform legislation.

I will withhold comment until I have a chance to carefully read and consider the document.

Atul Gawande - "The Cost Conundrum"

Atul Gawande's observations in the New Yorker about McAllen, Texas which have influenced political figures and at least one health care economist with whom I recently met. Click the title above for the link.

Thy Name Is Frailty

For a number of years, I was the medical director of a residential facility/nursing home (now "closed") for elderly professional women. There, I encountered many whom I classified as frail based on a combination of age, weakness, memory loss, inability to walk securely, limited vision, deficient hearing, problems performing daily living, a host of illnesses and a certain sadness, often associated with family inattention. It was not only these issues that used to worry me about these patients, it was that the functional deficiencies were coupled with serious illnesses requiring powerful medications which had significant side-effects.

So, I read with interest Medicare Risk Adjustment for the Frail Elderly* which describes CMS' interest in incorporating risk adjustment methodology into payment for "Medicare Advantage and other Medicare private organizations." CMS works with a frailty definition which focuses on functional impairment and difficulty in performance of activities of daily living ("ADL"). CMS' interest is provoked primarily by its role as a payer, rather than any clear pursuit of improvement in the quality of care and outcome benefit. And like most bureaucratic organizations, CMS adopts measurement tools which are based on paper (or in these days, perhaps electronic) records rather than field evaluation of a sample population using the eyes, ears, hands and minds of skilled evaluators.

In the past, as its resources have been limited, CMS reduced capitation payments for patients with high ADL scores, citing its models and actuarial studies. My experience as a physician was that patients would minimize or deny their limitations, and only when confronted by persons familiar with their daily capabilities, finally acknowledge their incapacities. In short, a paper/electronic record approach would seriously underestimate the magnitude of the problem.

Perhaps CMS should require its theorists to incorporate a requirement for actual independent field evaluation of the frailty of its clientele and use that adjuster to enhance its bureaucratic mission. That would be fair to those affected and served by the private Medicare companies, including Medicare Advantage plans.

*Health Care Financing Review/Winter 2008-2009, pp. 83-93.

Read Before Reaching For The Bug Spray

When I practiced hematology , I frequently saw new leukemic patients with strong insecticide exposure histories. The scientific literature did not then support the association, though many experienced hematologists suspected that it was only a matter of time before a link was established.

The time has arrived. A link between certain insecticides, fumigants and other pesticides with a condition which may represent the early bone cancer, multiple myeloma, is described in a release by the American Society of Hematology. Click this blog's title to be linked.

Once again, Our Health System may be impacted by products and uses which are the environmental "hit" which makes genetically prediposed persons sick. So pass on the insecticide spray and pick up the fly swatter. Visit your local organic farmers' market.