This is what I wrote to several newspaper editors and political figures several days ago:
Health insurers, pharmaceutical companies, hospitals and durable medical equipment suppliers have prospered in the last ten years as our citizens have struggled to obtain affordable, accessible, high quality health care. Bureaucratic roadblocks (insurers), excessive prices charged in the United States (pharmaceuticals), monopolization of hospital facilities (for-profit and regional systems) and marketing of expensive questionably necessary equipment ("scooters") threaten to bankrupt our nation without reducing infant mortali ty, death from breast cancer, or improving real health quality. As our next step, we need evidence-based health services, elimination of wasteful franchises, meaningful competition and elimination of government-expensed high-profit low value equipment gimmicks. Who will take the lead and when will the agenda be drafted and accomplished?
Sunday, March 28, 2010
Sunday, March 21, 2010
Thursday's Lunch
I met with the Thursday doctors' lunch group on March 18, 2010, and found a significant level of apprehension, questioning and mistrust concerning health reform.The first issue was the lack of information on how the ever-changing contents of the reform proposal would affect the practice and economics of physicians. Physicians noted that an ever-increasing number of doctors in our community is moving to concierge practices or refusing new Medicare patients (they had long-ago stopped taking MediCal [Medicaid] because they felt that it was a path to financial ruin). One doctor had called the American Medical Association and found that they were uninformed about new developments in health reform and he related that only the promise of elimination of the 21.5% cut in Medicare payment kept the AMA supporting reform. None of the physicians was trusting of the alliance between the government and health insurers because of their long experience with both. All in all, this group of physicians seemed depressed over their futures.
Wednesday, March 17, 2010
Hype: Fraud and Abuse Enforcement Will Have A Major Impact on Health Care Costs
Health care fraud and abuse enforcement will yield major program savings only if there is a cultural change among errant health care providers which leads them to believe that they shouldn't steal health care dollars.
Why should we believe that federal fraud and abuse investigation and prosecution will yield major savings under health care reform? My experience as a health care attorney was that federal attorneys would focus on a case only if there was an opportunity to recover a large sum relatively quickly for the government. They were not interested in spending their energy and government resources unless there was a significant return on the dollars invested in investigation and prosecution. Until federal attorneys' promotions, recommendations and career evaluations include consideration of their success in changing the culture which fosters fraudulent activities, rather than just how much money they rake in for the government, they will have no major incentive to attack the low level operators who do not seem to pose much of a threat to our society, but in total, bleed enormous sums from our health care system.
Why should we believe that federal fraud and abuse investigation and prosecution will yield major savings under health care reform? My experience as a health care attorney was that federal attorneys would focus on a case only if there was an opportunity to recover a large sum relatively quickly for the government. They were not interested in spending their energy and government resources unless there was a significant return on the dollars invested in investigation and prosecution. Until federal attorneys' promotions, recommendations and career evaluations include consideration of their success in changing the culture which fosters fraudulent activities, rather than just how much money they rake in for the government, they will have no major incentive to attack the low level operators who do not seem to pose much of a threat to our society, but in total, bleed enormous sums from our health care system.
Tuesday, March 16, 2010
Medicine: Art and Science
One day, I examined a patient who came to the office complaining about a "cold" and found a breast lump which another doctor had not found earlier that day. I visited her in the hospital, following her cancer surgery, and she asked me "after all, I only came in for a cold; why did you find the cancer that Dr. ***** couldn't find?" I gave her the best answer I knew: we all recognize in looking at a work of art that some of us see things that others don't; similarly, each well-trained and skilled physician may recognize something significant in an examination that the next physician may not appreciate.
I thought about my answer recently as I went from physician to physician seeking a diagnosis and appropriate treatment for my own painful condition. One doctor found the answer to one issue, but missed others; the second had a list of differential diagnoses pertinent to his own field, and when my diagnosis did not match his list, I knew it was time to move on; the third doctor put two and two together and came up with four, but the answer was really five, as I learned today from the next doctor in my tour of specialists in the Bay Area. Fortunately, "5" is benign and treatable.
The message to my readers is that medicine is a blend of art and science. The scope of knowledge and experience required for the diagnosis and treatment for a complex patient may go beyond what we can reasonably expect of a single physician or single system. Patients must some times be willing to put aside their confidence and implicit trust in their physicians or health systems to seek more complete and appropriate answers elsewhere. It isn't that their physicians or health systems are incompetent: it is that they represent humans who are limited in their capacities to solve all problems, even when they practice within the standards of their professions. Sometimes a second or third opinion is needed. Sometimes two plus two equals five.
I thought about my answer recently as I went from physician to physician seeking a diagnosis and appropriate treatment for my own painful condition. One doctor found the answer to one issue, but missed others; the second had a list of differential diagnoses pertinent to his own field, and when my diagnosis did not match his list, I knew it was time to move on; the third doctor put two and two together and came up with four, but the answer was really five, as I learned today from the next doctor in my tour of specialists in the Bay Area. Fortunately, "5" is benign and treatable.
The message to my readers is that medicine is a blend of art and science. The scope of knowledge and experience required for the diagnosis and treatment for a complex patient may go beyond what we can reasonably expect of a single physician or single system. Patients must some times be willing to put aside their confidence and implicit trust in their physicians or health systems to seek more complete and appropriate answers elsewhere. It isn't that their physicians or health systems are incompetent: it is that they represent humans who are limited in their capacities to solve all problems, even when they practice within the standards of their professions. Sometimes a second or third opinion is needed. Sometimes two plus two equals five.
Tuesday, March 9, 2010
We Don't Need No ***** Health Care Reform
Insurers, pharmaceutical companies, advertising agencies, national hospital associations, and other trade organizations whose influence with Congress now dictates America's response to proposals for health care reform are correct. The system we have works and our ranking in the mid-30s of the worlds nations for our health care quality is adequate since anyone who is truly rich, employed, worthy and well-connected can get all of the health care that he or she needs (provided it is approved by insurance company bureaucrats whose pay and bonuses depend on their success at limiting care and retroactively canceling sick customers' insurance). If Obama's health reform is defeated, as insurers, pharmaceutical companies, advertising agencies have determined is best for the country, the following will be just little bumps in the health care road.
1. Choose to have your heart attack, auto accident or fall from a tall ladder when the hospital emergency departments are not chock-full of those pesky uninsured people who can't afford to get health care from doctors during the day. If you get there in the peak uninsured persons' time, you might have to wait for service for just a few hours.
2. Tell your kids to stay home in front of their computers and TV sets, rather than play with the neighborhood kids because one of those kids might have a cough from infectious tuberculosis which hasn't been treated because his mom and dad aren't working and they don't have health care insurance any more.
3. Fire your babysitter, your gardener, your domestic help and and anyone else who comes to your house because with these low-level jobs it is unlikely they have health insurance and who knows what diseases they could be incubating?
4. Home school your kids so that you can limit their exposure to infectious diseases from some of their unworthy uninsured classmates.
5. Don't ever eat in a restaurant because the kitchen help or the waiters serving you might be sick and might pass the sickness on to you when the food is prepared or served.
6. Never take public transportation (trains, subways, buses, airplanes, ships, ferries, elevators, shared taxis) because the uninsured person sweating and coughing next to you, who couldn't afford to see a doctor about his fever, might have influenza, cancer, cholera, diphtheria or some other awful disease that he contracted but remains undiagnosed and untreated and maybe you'll catch.
7. Be sure to be nice to that woman whose child has just been diagnosed with leukemia but can't have a life-saving bone marrow or stem-cell transplant because the child is uninsured and mom and dad haven't sold off all of their assets yet to qualify for Medicaid.
8. Be sure to avoid that person who mutters to himself and threatens passers-by because he has paranoid schizophrenia but no supervision of his medications and no insurance to pay for them. Soon the police will be along to taser or shoot him, but their services don't come from the health care budget.
9. When they close the hospitals near your home or workplace in the interest of "efficiency" and "saving money," your new employer-provided health insurance may provide a perfectly satisfactory substitute hospital on another continent. staffed by people who might speak your language. On the other hand, your insurer may offer a nurse call service which can tell you how to set a broken arm with stuff your husband has in his garage workshop.
10. When new drugs, devices, technology and procedures are developed they will be available to politicians, bankers, financial people and CEOs under their insurance policies, but unfortunately, not to you and your family.
11. Your new employer-provided health insurance policy may provide for regularly scheduled office visits to the doctor. The new standard visit may be 3 minutes long, of which 2 minutes will be spent by the doctor entering stuff into the computer terminal.
12. Your doctor works from 9-12, 1-5 PM in the office, will not see you in the hospital, and knows nothing about the people who will see you in the hospital including their names, qualifications or experience.
13. All of that money you spent on life insurance will be very-much appreciated by your family.
1. Choose to have your heart attack, auto accident or fall from a tall ladder when the hospital emergency departments are not chock-full of those pesky uninsured people who can't afford to get health care from doctors during the day. If you get there in the peak uninsured persons' time, you might have to wait for service for just a few hours.
2. Tell your kids to stay home in front of their computers and TV sets, rather than play with the neighborhood kids because one of those kids might have a cough from infectious tuberculosis which hasn't been treated because his mom and dad aren't working and they don't have health care insurance any more.
3. Fire your babysitter, your gardener, your domestic help and and anyone else who comes to your house because with these low-level jobs it is unlikely they have health insurance and who knows what diseases they could be incubating?
4. Home school your kids so that you can limit their exposure to infectious diseases from some of their unworthy uninsured classmates.
5. Don't ever eat in a restaurant because the kitchen help or the waiters serving you might be sick and might pass the sickness on to you when the food is prepared or served.
6. Never take public transportation (trains, subways, buses, airplanes, ships, ferries, elevators, shared taxis) because the uninsured person sweating and coughing next to you, who couldn't afford to see a doctor about his fever, might have influenza, cancer, cholera, diphtheria or some other awful disease that he contracted but remains undiagnosed and untreated and maybe you'll catch.
7. Be sure to be nice to that woman whose child has just been diagnosed with leukemia but can't have a life-saving bone marrow or stem-cell transplant because the child is uninsured and mom and dad haven't sold off all of their assets yet to qualify for Medicaid.
8. Be sure to avoid that person who mutters to himself and threatens passers-by because he has paranoid schizophrenia but no supervision of his medications and no insurance to pay for them. Soon the police will be along to taser or shoot him, but their services don't come from the health care budget.
9. When they close the hospitals near your home or workplace in the interest of "efficiency" and "saving money," your new employer-provided health insurance may provide a perfectly satisfactory substitute hospital on another continent. staffed by people who might speak your language. On the other hand, your insurer may offer a nurse call service which can tell you how to set a broken arm with stuff your husband has in his garage workshop.
10. When new drugs, devices, technology and procedures are developed they will be available to politicians, bankers, financial people and CEOs under their insurance policies, but unfortunately, not to you and your family.
11. Your new employer-provided health insurance policy may provide for regularly scheduled office visits to the doctor. The new standard visit may be 3 minutes long, of which 2 minutes will be spent by the doctor entering stuff into the computer terminal.
12. Your doctor works from 9-12, 1-5 PM in the office, will not see you in the hospital, and knows nothing about the people who will see you in the hospital including their names, qualifications or experience.
13. All of that money you spent on life insurance will be very-much appreciated by your family.
Wednesday, March 3, 2010
Reform, Not Minimalism "Where's The Beef?"
I spent lots of time on National Health Lawyers Association activities in Washington, DC during Ronald Reagan's administration and remember the awesome power and control that President Reagan exercised through the House-Senate conference committee process. It would be hard for the current generation of Republicans to deny their Reagan heritage and cry foul should President Obama emulate Reagan's example with respect to reforming our health system.
But if Obama is going to use his presidential authority and legislative majorities to get the job done, it should be for major health care reform, not the minimalist program spelled-out in today's communique from the White House (Click Title for "Where's The Beef"):
"On Wed, Mar 3, 2010 at 11:45 AM, President Barack Obama wrote:
"Friend --
"Last Thursday's first-of-its-kind summit capped off a debate that has lasted nearly a year. Every idea has now been put on the table. Every argument has been made. Both parties agree that the status quo is unacceptable and gets more dire each day. Today, I want to state as clearly and forcefully as I know how: Now is the time to make a decision about the future of health care in America.
"The final proposal I've put forward draws on the best ideas from all sides, including several put forward by Republicans at last week's summit. It will put Americans in charge of their own health care, ensuring that neither government nor insurance company bureaucrats can ration, deny, or put out of financial reach the care our families need and deserve.
"I strongly believe that Congress now owes the American people a final vote on health care reform. Reform has already passed the House with bipartisan support and the Senate with a super-majority of sixty votes. Now it deserves the same kind of up-or-down vote that has been routinely used and has passed such landmark measures as welfare reform and both Bush tax cuts.
"Earlier today, I asked leaders in both houses of Congress to finish their work and schedule a vote in the next few weeks. From now until then, I will do everything in my power to make the case for reform. And now, I'm asking you, the members of the Organizing for America community, to raise your voice and do the same.
"The final march for reform has begun, and your participation is crucial. Please commit to join with me to take reform across the finish line.
"Essentially, my proposal would change three things about the current health care system:
"First, it would protect all Americans from the worst practices of insurance companies. Never again will the mother with breast cancer have her coverage revoked, see her premiums arbitrarily raised, or be forced to live in fear that a pre-existing condition will bar her from future coverage.
"Second, my proposal would give individuals and small businesses the same choice of private health insurance that members of Congress get for themselves. And my proposal says that if you still can't afford the insurance in this new marketplace, we will offer you tax credits based on your income -- tax credits that add up to the largest middle class tax cut for health care in history.
"Finally, my proposal would bring down the cost of health care for everyone -- families, businesses, and the federal government -- and bring down our deficit by as much as $1 trillion over the next two decades. These savings mean businesses small and large will finally be freed up to create jobs and increase wages. With costs currently skyrocketing, reform is vital to remaining economically strong in the years and decades to come.
"In the few crucial weeks ahead, you can help make sure this proposal becomes law. Please sign up to join the Organizing for America campaign in the final march for reform:
http://my.barackobama.com/commit
"When I talked about change on the campaign, this is what I was talking about: coming together to solve a huge problem that has been troubling America for 100 years and standing up to the special interests to deliver a brighter, smarter future for generations to come.
"I look forward to signing this historic reform into law. And when I do, it will be because your organizing played an essential role in making change possible.
"Thank you,
President Barack Obama"
MY OPINION
America needs reform which will provide: (1) efficient basic accessible, ethical, scientifically appropriate, health care, pharmaceutical product and health insurance coverage for every citizen in America; (2) a health care work force including physicians, nurses and other personnel, which is adequate in number, well-educated, highly competent, and incentivized to provide appropriate high quality health services; (3) a system, including but not limited to, a federal independent agency provider, which provides economically sound medically necessary, scientifically well-founded, and appropriate health services 24 hours a day, 7 days a week, 365 days per year; (4) appropriate incentives for high level mathematical and scientific student and post-graduate training; (5) a respected and appropriately supported system of national public health services which will coordinate and manage health care emergencies including epidemics, national disasters, bio-terrorism episodes, nuclear disasters and other events; (6) national licensing of health care providers; (7) support for local, national and internationally based health care fraud detection, prosecution and punishment; (7) continued support for scientific research; (8) appropriate quality, professional and financial standards for all institutional providers of health services including hospitals, outpatient facilities, research institutions dealing directly with patients; (9) independent objective public health education; and (10) encouragement and support of the development of enforceable ethical standards related to health care, health-related information, and products which purport to effect health care.
But if Obama is going to use his presidential authority and legislative majorities to get the job done, it should be for major health care reform, not the minimalist program spelled-out in today's communique from the White House (Click Title for "Where's The Beef"):
"On Wed, Mar 3, 2010 at 11:45 AM, President Barack Obama
"Friend --
"Last Thursday's first-of-its-kind summit capped off a debate that has lasted nearly a year. Every idea has now been put on the table. Every argument has been made. Both parties agree that the status quo is unacceptable and gets more dire each day. Today, I want to state as clearly and forcefully as I know how: Now is the time to make a decision about the future of health care in America.
"The final proposal I've put forward draws on the best ideas from all sides, including several put forward by Republicans at last week's summit. It will put Americans in charge of their own health care, ensuring that neither government nor insurance company bureaucrats can ration, deny, or put out of financial reach the care our families need and deserve.
"I strongly believe that Congress now owes the American people a final vote on health care reform. Reform has already passed the House with bipartisan support and the Senate with a super-majority of sixty votes. Now it deserves the same kind of up-or-down vote that has been routinely used and has passed such landmark measures as welfare reform and both Bush tax cuts.
"Earlier today, I asked leaders in both houses of Congress to finish their work and schedule a vote in the next few weeks. From now until then, I will do everything in my power to make the case for reform. And now, I'm asking you, the members of the Organizing for America community, to raise your voice and do the same.
"The final march for reform has begun, and your participation is crucial. Please commit to join with me to take reform across the finish line.
"Essentially, my proposal would change three things about the current health care system:
"First, it would protect all Americans from the worst practices of insurance companies. Never again will the mother with breast cancer have her coverage revoked, see her premiums arbitrarily raised, or be forced to live in fear that a pre-existing condition will bar her from future coverage.
"Second, my proposal would give individuals and small businesses the same choice of private health insurance that members of Congress get for themselves. And my proposal says that if you still can't afford the insurance in this new marketplace, we will offer you tax credits based on your income -- tax credits that add up to the largest middle class tax cut for health care in history.
"Finally, my proposal would bring down the cost of health care for everyone -- families, businesses, and the federal government -- and bring down our deficit by as much as $1 trillion over the next two decades. These savings mean businesses small and large will finally be freed up to create jobs and increase wages. With costs currently skyrocketing, reform is vital to remaining economically strong in the years and decades to come.
"In the few crucial weeks ahead, you can help make sure this proposal becomes law. Please sign up to join the Organizing for America campaign in the final march for reform:
http://my.barackobama.com/commit
"When I talked about change on the campaign, this is what I was talking about: coming together to solve a huge problem that has been troubling America for 100 years and standing up to the special interests to deliver a brighter, smarter future for generations to come.
"I look forward to signing this historic reform into law. And when I do, it will be because your organizing played an essential role in making change possible.
"Thank you,
President Barack Obama"
MY OPINION
America needs reform which will provide: (1) efficient basic accessible, ethical, scientifically appropriate, health care, pharmaceutical product and health insurance coverage for every citizen in America; (2) a health care work force including physicians, nurses and other personnel, which is adequate in number, well-educated, highly competent, and incentivized to provide appropriate high quality health services; (3) a system, including but not limited to, a federal independent agency provider, which provides economically sound medically necessary, scientifically well-founded, and appropriate health services 24 hours a day, 7 days a week, 365 days per year; (4) appropriate incentives for high level mathematical and scientific student and post-graduate training; (5) a respected and appropriately supported system of national public health services which will coordinate and manage health care emergencies including epidemics, national disasters, bio-terrorism episodes, nuclear disasters and other events; (6) national licensing of health care providers; (7) support for local, national and internationally based health care fraud detection, prosecution and punishment; (7) continued support for scientific research; (8) appropriate quality, professional and financial standards for all institutional providers of health services including hospitals, outpatient facilities, research institutions dealing directly with patients; (9) independent objective public health education; and (10) encouragement and support of the development of enforceable ethical standards related to health care, health-related information, and products which purport to effect health care.
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