A license to practice medicine, or function as a health care professional in any of the allied fields which require government certification, is a franchise. It gives the holder the unique ability - in the furtherance of public interest - to provide personal and technical health services in exchange for payment - to people within its jurisdiction. Non-licensed persons cannot hold themselves out as able to provide and charge for those services. A franchise protects its holder from competetition.
The report that a nationally recognized medical organization has refused to provide further or future care to Medicare beneficiaries is disturbing. It is inconsistent with the essential caring spirit of physicians, nurses and other health care professionals and institutions and and contrary to the public service requirement that the franchise invokes. Systematic exclusion from receipt of services because one is a Medicare beneficiary is un-American and wrong.
The United States needs a reformed national health care system, not parochial local or state operations. The essential requirement for critical health care services, such as obstetrics, cancer treatment, fracture care, treatment of devastating infections and the skills, equipment and facilities necessary to deliver these services doesn't change from rural Georgia to Arizona or Ohio. State licensure of health care personnel is an anachronism: if a physician has the requisite evidence of competence and personal conduct qualifications to provide care in New York, why should that person be forbidden to practice medicine in Utah without going through an entirely new, expensive, time consuming and resource wasting evaluation. If a physician in Florida has practiced competently for fifteen years and moves to Minnesota, why impede that change by measures which are formulated specifically to reduce competition in the guise of "licensure quality"? Why not have federal licensing in full recognition that the federal government is the major funder of health care services and facilities? Why not have federal standards which will protect every patient and every provider in the United States rather than the wasteful duplication of political-administrative functions in every jurisdiction in our nation?
Physicians and other providers know that dealing with health care insurers is more disruptive to their practices, in terms of inadequate compensation, bureaucratic bottlenecks and denial of essential services to patients, than dealing with the federal government. The federal government, hamstrung by political contributions and lobbying, has not engaged with insurers to set matters right except for patients covered by Medicare. There is no fair uniform protection of patients and health care providers from financial ruin in the event of medical malpractice or the determination that malpractice has occurred (the public is not aware of the extraordinary cost of medical malpractice insurance to many practitioners, including those who have never lost a malpractice lawsuit). Our government has failed to deal with inflation in pharmaceutical costs and its impact on health care providers, patients and their families. The federal government has cost-shifted its drug war by imposing $500 fees on providers for a 3-year Drug Enforcement Administration license, using health care providers as cash-cows rather than as a vital part of our system of health care.
The government grants a franchise. Providers have to provide necessary health services to all of the public that the franchise envisions. And government has to reasonably protect health care providers, and all Americans, from being financially gouged by parasitic uncontrolled interests including those masquerading as government agencies or licensees or contractors. If not, as is the case today, we all lose.
Tuesday, January 26, 2010
Wednesday, January 20, 2010
Executive Authority - An Exquisite Tool for Health System Reform
In light of Congressional leadership mismanagement of proposals for health reform, the burden of setting healthcare "right" will move to President Obama. Perhaps his advisors should be thinking about those features of serious health system reform which could be implemented under the the President's executive powers (could Republicans deny such authority with straight faces?). For instance, how could executive powers support education in the sciences, including graduate and postgraduate training in the various medical skills our health care system will need as our population grows and ages? How could federal responsibility for veterans' and public health services evolve into a model system for delivering health services? How should federal support for Medicaid be administered to achieve significant societal good? How should we structure our priorities and ethical principles?
The President is not without tools.
The President is not without tools.
Tuesday, January 19, 2010
Haiti & Texas & Silicon Valley
In Judiasm we pray that "our houses will not become our graves."
Throughout time, our land has been restless, unpredictably moving. Sometimes our history records that mountains skip like rams or lambs. So last week's events which destroyed life, limb, homes, hospitals, the economy and infrastructure on the Haitian end of the island through which a known geologic fault coursed, was in a sense, not a surprise. It is the way of the world.
Now we hear whining self-promoting television reporters complaining that Haitian medical facilities are inadequate, that there are not enough operating rooms, that there are insufficient numbers of physicians and nurses, that there are not enough beds, that there are insufficient supplies of equipment and medicines. Sorry, but these same insufficiencies in Haiti did not make CNN headlines before the dramatic earthquake, so why the feigned surprise. Haiti is a poor country led by stealing despots who have kept their people in the prison of poverty for years. Health care was not a leading priority. No-one traveled to Haiti to get first class health care.
I have lived in Silicon Valley for more than forty years. Our geography reflects our precarious perch where two geologic plates meet. In 1985 we had an earthquake with the most rapid ground movement ever recorded (I was on the 9th floor of a medical building on my belly holding on). The building had been properly earthquake engineered and survived that event without damage. In 1989, just as I finished seeing my last office patient for the day, a 7+ (Richter Scale) earthquake (comparable in scale to the Haiti earthquake) tore through our valley where it produced relatively little damage to our health care infrastructure because we had stringent earthquake building safety codes Fortunately the hospital where I had been chief of staff and board member had remedied a potentially fatal weakness in its structure five years earlier.
So what does all of this have to do with Haiti and Texas?
More than 30 years ago, a study, which in my opinion was of poor quality, was published in Texas which became the touchstone for generations of hospital closures. The study described the savings which closure of hospitals which were not overflowing with patients, could reap. Nationwide, citing this weak study, hospitals and medical facilities were pressured to close because they were "inefficient" and money could be garnered if their equipment was sold to speculators or third world countries and their land used for commerce. Some for-profit hospital companies speeded-up this process of closure as they acquired competing hospitals and closed-down the competition with relatively little in the way of active opposition from government entities.
So when we have our next big earthquake, if Los Gatos' Lexington Dam collapses innundating several medical institutions in the flood plain below it, and the closed hospitals are not there to absorb the flood of sick and injured patients, and the doctors who have left the area are no longer available to provide services, will CNN be there to say "we should have learned from Haiti" or will they simply rant and rave until the publilc loses interest and turns to other entertainment.
Or if we have a terrorist dirty bomb, or a high-powered nuclear weapon attack, where will we take care of our population and who will take care of our people? If we have a horrible epidemic or biologic or chemical attack, where will we take care of our population. What if we have a natural catastrophe of greater magnitude than we have in our local recorded history? Will we resort the curbside medical care, hacksaw amputations and mass graves?
Many of the issues which existed in Haiti before the earthquake have comparable issues in the United States today. If the focus of "health car reform" is to wring every dollar out of health care, without concern for quality, ethics, availability and competence, perhaps we had better hope that the Israelis can set up emergency hospitals in our big cities because our government has demonstrated that it cannot. Some duplication in health care facilities and personnel, as protection against injury and illness resulting from an unplanned catastrophe, is an imperative. Shall we ignore the lesson of Haiti?
Throughout time, our land has been restless, unpredictably moving. Sometimes our history records that mountains skip like rams or lambs. So last week's events which destroyed life, limb, homes, hospitals, the economy and infrastructure on the Haitian end of the island through which a known geologic fault coursed, was in a sense, not a surprise. It is the way of the world.
Now we hear whining self-promoting television reporters complaining that Haitian medical facilities are inadequate, that there are not enough operating rooms, that there are insufficient numbers of physicians and nurses, that there are not enough beds, that there are insufficient supplies of equipment and medicines. Sorry, but these same insufficiencies in Haiti did not make CNN headlines before the dramatic earthquake, so why the feigned surprise. Haiti is a poor country led by stealing despots who have kept their people in the prison of poverty for years. Health care was not a leading priority. No-one traveled to Haiti to get first class health care.
I have lived in Silicon Valley for more than forty years. Our geography reflects our precarious perch where two geologic plates meet. In 1985 we had an earthquake with the most rapid ground movement ever recorded (I was on the 9th floor of a medical building on my belly holding on). The building had been properly earthquake engineered and survived that event without damage. In 1989, just as I finished seeing my last office patient for the day, a 7+ (Richter Scale) earthquake (comparable in scale to the Haiti earthquake) tore through our valley where it produced relatively little damage to our health care infrastructure because we had stringent earthquake building safety codes Fortunately the hospital where I had been chief of staff and board member had remedied a potentially fatal weakness in its structure five years earlier.
So what does all of this have to do with Haiti and Texas?
More than 30 years ago, a study, which in my opinion was of poor quality, was published in Texas which became the touchstone for generations of hospital closures. The study described the savings which closure of hospitals which were not overflowing with patients, could reap. Nationwide, citing this weak study, hospitals and medical facilities were pressured to close because they were "inefficient" and money could be garnered if their equipment was sold to speculators or third world countries and their land used for commerce. Some for-profit hospital companies speeded-up this process of closure as they acquired competing hospitals and closed-down the competition with relatively little in the way of active opposition from government entities.
So when we have our next big earthquake, if Los Gatos' Lexington Dam collapses innundating several medical institutions in the flood plain below it, and the closed hospitals are not there to absorb the flood of sick and injured patients, and the doctors who have left the area are no longer available to provide services, will CNN be there to say "we should have learned from Haiti" or will they simply rant and rave until the publilc loses interest and turns to other entertainment.
Or if we have a terrorist dirty bomb, or a high-powered nuclear weapon attack, where will we take care of our population and who will take care of our people? If we have a horrible epidemic or biologic or chemical attack, where will we take care of our population. What if we have a natural catastrophe of greater magnitude than we have in our local recorded history? Will we resort the curbside medical care, hacksaw amputations and mass graves?
Many of the issues which existed in Haiti before the earthquake have comparable issues in the United States today. If the focus of "health car reform" is to wring every dollar out of health care, without concern for quality, ethics, availability and competence, perhaps we had better hope that the Israelis can set up emergency hospitals in our big cities because our government has demonstrated that it cannot. Some duplication in health care facilities and personnel, as protection against injury and illness resulting from an unplanned catastrophe, is an imperative. Shall we ignore the lesson of Haiti?
Tuesday, January 12, 2010
A Free Market Approach To Parental Refusal To Vaccinate
In a recent study reported to physicians by Medscape (the original article appeared in the January issue of the Archives of Pediatrics & Adolescent Medicine), approximately 5% of the children who were studied did not have varicella vaccination because of parental refusal. The study found that the children whose parents refused to have their children immunized were at "high risk" of varicella infection compared to children who were vaccinated.
Today, a parent's refusal to vaccinate with a medically proved effective and safe vaccine has no societal consequences for the parent other than the guilt which he or she may shoulder from severe complications of varicella infection in his or her child. Other parents, and their children who become infected as a consequence of each refuser's decision (such as children with immune disorders or leukemia who cannot be vaccinated) unfairly bear all of the financial and personal liability flowing from the original refuser's decision, a decision in which they did not participate.
A straightforward marketplace approach to the parents' vaccination decision making could be relatively simple. After being provided with relevant information, a parent who denies his or her child the protection of vaccination (or does not present the child for vaccination) becomes liable for all economic and "pain and suffering" consequences of all downstream infections which can be traced back to that child by public health authorities. Guaranteed freedom of choice, the refuser could insure against such liability, or could post a bond which he or she purchases.
Adoption of this approach would reduce the cost of health care because it would prevent the refusing parent from shifting the cost of the decision to payers and other parents. The refusing parent could reduce his or her exposure to liability through insurance, bringing the opportunity for new business to insurers. Attorneys actuaries, public health officials could be engaged in the "fight against preventable disease". It's a "win-win".
Today, a parent's refusal to vaccinate with a medically proved effective and safe vaccine has no societal consequences for the parent other than the guilt which he or she may shoulder from severe complications of varicella infection in his or her child. Other parents, and their children who become infected as a consequence of each refuser's decision (such as children with immune disorders or leukemia who cannot be vaccinated) unfairly bear all of the financial and personal liability flowing from the original refuser's decision, a decision in which they did not participate.
A straightforward marketplace approach to the parents' vaccination decision making could be relatively simple. After being provided with relevant information, a parent who denies his or her child the protection of vaccination (or does not present the child for vaccination) becomes liable for all economic and "pain and suffering" consequences of all downstream infections which can be traced back to that child by public health authorities. Guaranteed freedom of choice, the refuser could insure against such liability, or could post a bond which he or she purchases.
Adoption of this approach would reduce the cost of health care because it would prevent the refusing parent from shifting the cost of the decision to payers and other parents. The refusing parent could reduce his or her exposure to liability through insurance, bringing the opportunity for new business to insurers. Attorneys actuaries, public health officials could be engaged in the "fight against preventable disease". It's a "win-win".
Saturday, January 9, 2010
Sonic Hedgehog, Airport Security and Civil Rights
One day soon, you may find yourself in a long airport line, waiting to be total body scanned for explosives or other terrorist devices. Microwave technology scanning is not the subject of this blog: ionizing radiation total body scanning is. And, as the New York Times reported on 1/9/2010 (p. A4) since Congress has now appropriated money for the placement of 450 scanners in American airports, the risk of being exposed to ionizing radiation for non-medical purposes has just increased.
About 1 out of every 57,000 Americans has a genetic abnormality (of which most of them probably are unaware) in the Sonic Hedgehog protein pathway, a system involved in protection against cancer (i.e., skin cancer and a brain cancer called medullablastoma) and other tumors (i.e., of the ovary and heart). The resulting disorder is called Gorlin Syndrome or Basal Cell Nevus Syndrome. For these people, who are at significant risk of developing extraordinary numbers of unusual and often aggressive basal cell cancers of the skin , the key to primary prevention of skin manifestations, experts write, is "Sun exposure and x-irradiation should be avoided."
While the amount of radiation exposure from airport screening equipment may not be large, any radiation exposure stimulates immediate biologic response and for those with genetic disability of the Hedgehog signaling system, risk of cancer.
At a national scientific meeting of the American Society of Hematology several years ago, an elegant discussion of the mechanism of the body's immediate response to radiation exposure was presented to a large sophisticated audience, with an observation that the American government might be considering low level exposure of large segments of the American population so that in the event of a terrorist attack involving radiation, Americans might have pre-existing "immunity" .
So we have moved to a tension between national safety and individual health. Is anybody watching?
About 1 out of every 57,000 Americans has a genetic abnormality (of which most of them probably are unaware) in the Sonic Hedgehog protein pathway, a system involved in protection against cancer (i.e., skin cancer and a brain cancer called medullablastoma) and other tumors (i.e., of the ovary and heart). The resulting disorder is called Gorlin Syndrome or Basal Cell Nevus Syndrome. For these people, who are at significant risk of developing extraordinary numbers of unusual and often aggressive basal cell cancers of the skin , the key to primary prevention of skin manifestations, experts write, is "Sun exposure and x-irradiation should be avoided."
While the amount of radiation exposure from airport screening equipment may not be large, any radiation exposure stimulates immediate biologic response and for those with genetic disability of the Hedgehog signaling system, risk of cancer.
At a national scientific meeting of the American Society of Hematology several years ago, an elegant discussion of the mechanism of the body's immediate response to radiation exposure was presented to a large sophisticated audience, with an observation that the American government might be considering low level exposure of large segments of the American population so that in the event of a terrorist attack involving radiation, Americans might have pre-existing "immunity" .
So we have moved to a tension between national safety and individual health. Is anybody watching?
Sunday, January 3, 2010
Resurrect and Reinvigorate the Miasma Theory
In the two well-organized and coordinated November 2009 public health vaccination sessions in which I participated as a volunteer physician vaccinator, Santa Clara County California provided H1N1 influenza vaccine to approximately 10,000 men, women and children, many of whom lined-up beginning at 1:30 in the dark of night to be sure they would get their vaccine.
As I checked paperwork, inspected vaccine-filled hypodermic syringes, and went through the process of injecting H1N1 vaccine, I gained an important insight by speaking with the people who were there to get their shots: they understood that prevention of disease, through vaccination, was much better than trying to treat an established influenza infection. They understood that prevention was better than treatment.
The health care reform proposal before Congress pictures systems of highly organized and technologically well equipped facilities staffed by serious people wearing spotless white coats and speaking scientific gibberish such as one would hear on television crime and hospital programs. When prevention is mentioned, it is focused on esoteric highly technical medical practices and procedures which were unimaginable fifty or one hundred years ago.
Until the germ theory was proposed in the 1800s, people believed the miasma was responsible for serious diseases. Miasma was considered to be a poisonous vapor or mist filled with particles from decomposed matter (miasmata) that caused illnesses. It was identifiable by its foul smell. In its modern incarnation, perhaps we should view polluted water, air, the absence of a protective ozone layer, contamination in food products, hog and cattle waste ponds, destruction of our forests, spoilation of land through unsafe mining practices and similar activities as our miasma. And perhaps we should, like the people who stood all night waiting in line to get their preventive H1N1 flu vaccine injections, not emphasize treatment of the diseases caused by our new miasma, but prevent these diseases by cleaning up our water supply, enforcing clean air regulations nationwide, appropriately regulating the food industry, regulating agricultural environmental destruction, controlling clear-cutting and other wasteful forest destruction practices, and preventing mining from using valleys, lakes and homesights as waste pits.
The people who stood in line "got it". Now, will our state and federal politicians and bureaucracies demonstrate that they, too, understand that prevention is better than treatment? Or will their deference to special interests, and financial supporters, require continuing sacrifices of health by our ctizens?
As I checked paperwork, inspected vaccine-filled hypodermic syringes, and went through the process of injecting H1N1 vaccine, I gained an important insight by speaking with the people who were there to get their shots: they understood that prevention of disease, through vaccination, was much better than trying to treat an established influenza infection. They understood that prevention was better than treatment.
The health care reform proposal before Congress pictures systems of highly organized and technologically well equipped facilities staffed by serious people wearing spotless white coats and speaking scientific gibberish such as one would hear on television crime and hospital programs. When prevention is mentioned, it is focused on esoteric highly technical medical practices and procedures which were unimaginable fifty or one hundred years ago.
Until the germ theory was proposed in the 1800s, people believed the miasma was responsible for serious diseases. Miasma was considered to be a poisonous vapor or mist filled with particles from decomposed matter (miasmata) that caused illnesses. It was identifiable by its foul smell. In its modern incarnation, perhaps we should view polluted water, air, the absence of a protective ozone layer, contamination in food products, hog and cattle waste ponds, destruction of our forests, spoilation of land through unsafe mining practices and similar activities as our miasma. And perhaps we should, like the people who stood all night waiting in line to get their preventive H1N1 flu vaccine injections, not emphasize treatment of the diseases caused by our new miasma, but prevent these diseases by cleaning up our water supply, enforcing clean air regulations nationwide, appropriately regulating the food industry, regulating agricultural environmental destruction, controlling clear-cutting and other wasteful forest destruction practices, and preventing mining from using valleys, lakes and homesights as waste pits.
The people who stood in line "got it". Now, will our state and federal politicians and bureaucracies demonstrate that they, too, understand that prevention is better than treatment? Or will their deference to special interests, and financial supporters, require continuing sacrifices of health by our ctizens?
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