Universal Healthcare: A new Concept That Can Work

If you've read any of my previous posts, you'll know that I am not a firm believer that any of the proposed solutions to the current healthcare crisis will work. Universal healthcare is a lofty goal but if there is any hope that it will work, it has to involve every American as an invested individual, equally and fairly. In a conversation I was having with a few colleagues, an idea came to me that seems so simple it just has to work.

Let us assume that some form of universal healthcare will be enacted. We must also assume that in order for the insurance companies to survive, only the largest and most efficient, able to take advantage of economies of scale, will be likely to surivive. Participation in any form of universal healthcare will be mandatory, whether it is sponsored or offered by an employer or the government. You will have little or no choice. When there are only a few suppliers or producers, you have an oligopoly. An oligopoly is defined as "A market dominated by a small number of participants who are able to collectively exert control over supply and market prices". Does insurance fit his definition? Yes it will.

If we do have a situation where a few large suppliers or producers dominate a market, we as consumers, need regualtion and protection from them just like we do in the utilities markets. You may not be aware of their presence, but the public utilities commissions of your individual states make sure that the suppliers of your water, electric, natural gas, railways and telephone services are treating you, the public, fairly. They are also responsible for the oversight of those industries, review requests for rate increases and monitor the industry's return on equity and investment to their respective shareholders. Can this model be applied to health insurance? Absolutely.

Anthem BC/BS was a mutual insurance company until it changed it's status and was later acquired by Wellpoint, Inc. A mutual company is defined as " A company whose profits are distributed in proportion to the amount of business each participant does with the company". Sounds like a perfect structure for universal healthcare.

Since there will likely be mandaory participation, all payments to the insurance companies will come from the governement in the form of direct or indirect payments. If each household is given a "share" in their insurance provider for each covered life, that household has a direct invested interest in seeing that their insurance company is as successful and profitable as possible. They would be encouraged to utilize their healthcare resources only when necessary. Decreased utilization by the individual covered lives means lower insurance company expenses , greater profits and additional distributions (dividends) per covered lives. Since every person covered receives a share when they sign up for insurance, you receive a direct financial dividend when your insurance provider earns a profit. The most efficient insurance companies that are also providing the best healthcare benefit will naturaaaly attract more participants, increasing their efficiencies through economies of scale. In an effort to increase "shareholder" satisfaction, these companies, like their untility company counterparts, will seek to be more efficient, maximize value, return on investment and equity and take the greatest advantage of financial leverage.

Rather refreshing for an insurance company to be operating on your behalf, as a shareholder, instead of only a hostage or paying customer. It makes much more sense to combine the benefits of a regulated industry where each covered life is treated like a shareholder with a voice, in conjunction with what will be mandatory participation. Under this scenario, you are as important to the insurer as a consumer as you are as a shareholder. The shareholder's voice of displeasure can effect who runs the insurance company depending on how they vote at the annual shareholdeer's meeting.

You also have a voice on how well you feel your insurance provider cares for you as a consumer. If they do a good job, you'll tell others, attracting more members/shareholders. If you don't like how you are being treated, you'll change insurance carriers and tell all your friends and co-workers.

I don't have a lot of confidence in the government to fix the problems with healthcare and I have less confidence that the insurance industry will do anything in the indvidual's best interest unless they are made to do so. But, if I am in a position to benefit directly from their quality and efficient care to patients (me and mine), I would feel much better about universal healthcare, government regulation and the insurance companies continuing as ongoing concerns.

Doc B

My opinion is free.
Advice is worth exacly what you pay for it.

Bedbugs; Recurrence of an Age Old Scourge

When I was a child my parents would tuck me into bed and say "Sleep tight and don't let the bedbugs bite". It was horrifying to hear, especially as a child, but mostly because I had no idea what the hell they were talking about. I really had no idea they were even a real "bug" until the last few years. Bedbugs have made a roaring comeback. I believe the word "epidemic" is being used to describe their resurgence as one of the most difficult pests to eradicate. If you haven't been infested with them, you probably know someone who has.

Most people assume that if you have bugs you must be dirty. Not the case with bedbugs. They are a true non discriminating, equal opportunity offender. They do not care about your income level, age, sex, level of education or your fine pedigree. You are a warm blooded human being. They love you for who you are. You can provide a blood meal. You are perfect. Thank God they don't spread disease. At most they are a nuisance and may cause some itching or red spots, but they won't really do you any harm. Still, I just don't like the thought of the little buggers coming out of hiding at night to feast on my wonderfulness, while I'm sleeping.


A great website describing the life cycle of bedbugs, their preferred habitats, treatment options and some photographs can be found here. From what I can gather from news reports, articles and the website, we have a problem that we are not going to be able to control. Our most effective pesticide for combating bedbugs, DDT, was banned several years ago and that is when their numbers began to increase. Major metro areas are having problems that even their Departments of Health cannot afford to tackle.

Bedbugs can be spread during travel, from hotel rooms, hospitals, spring break, college dormitories and visiting the mansion down the street. They are everywhere and we have been helping them travel, by using us as their means of transportation. Once we drop our bedbug load, they make a home and start reproducing.

May be time to think about the development of new pesticides or at least take another look at DDT. If not, the time will come when everyone we know and everyplace we go will have them. I don't want to be an insects nightly snack. Do you?

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Back to Healthcare Related Issues

Now that the election is over and a Democrat will be taking office, maybe we can get back to where we were when Clinton was in office. During the Clinton years, stem cell research advanced by leaps and bounds. Researchers were on the verge of developing stem cell lines for the treatment of diabetes, parkinson's and advances in spinal cord injury. During the Bush administration's hysterical ban on embryonic stem cells, beginning in 2001 and at least until Barack Obama takes office, the development of new stem cell lines was essentially illegal.

What Bush did do inadvertently was to push stem cell research in new areas. Much of the research was done overseas in collaboration with their American counterparts. Researchers in the US were forced to develop methods to encourage their existing stem cells to become pluripotential again for differentiation into different cells. They also were able to find and exploit adult stem cells from the tissues and blood of adults. After a very slow start, the stem cell community is ripe for the development of multiple lines that have the potential to treat and/or cure many diseases. All they need is the support that Obama will have the authority to give.

Interestingly enough, both McCain and Obama support stem cell research. During the last 3 years they both supported the same four pieces of legislation regarding stem cell research, including embryonic stem cells. Their main area of disagreement was in the use of embryos created for use in fertility clinics. The excess embryos are typically destroyed. Obama supports their use while McCain did not. Both supported the ban on the use of embryos created for the sole purpose of research. Now that Obama is president, hopefully he can get legislation passed that allows the use of those excess embryos from fertility clinics for stem cell research.

I have a particularly strong personal interest in this area. Type 1 diabetes runs in my family. My father died of complications related to his diabetes after suffering a heart attack and an amputation of his lower leg due to poor circulation. He had diabetes for more than 50 years. When you think about, he actually did quite well considering the fact that most of the advances and understanding of diabetes occurred in the last twenty years. Unfortunately, diabetes is genetic. My daughter and I are also type 1 diabetics. My hope is that even if there is no "cure" during my lifetime, there will be for my daughter.

While it may seem initially that my motivation is selfish (and I admit that I am looking at this from a personal perspective also), the statistics are overwhelming and crying for a cure. The current estimates(2008) state that there are currently 21 million Americans with diabetes and 54 million with pre-diabetes. Deaths due to diabetes and it's complications are 224,000 per year. If the current trend continues, a person born in the year 2000 has a one in three chance of developing diabetes in their lifetime. For minorities, that lifetime chance of developing diabetes is a staggering one out of two!

The economic costs related to diabetes should place it on everyone's radar for control and cure. A paper published by the American Diabetes Association entitled Economic Costs of Diabetes in The U.S in 2007, estimates that in 2007 there were 17.5 million diagnosed diabetics and another 6.6 million who were undiagnosed. Combined, that represents 8% of the total US population. For the diagnosed diabetics, the ADA calculates the "economic burden of diabetes caused by increased health resource use" to be $174 Billion per year. The increasing prevalence of diabetes means increasing expenditures for years to come.

From a purely fiscal point of view, it would make sense to prevent or cure a disease that has such a high cost to society. This can be accomplished in many ways. Stem cell research can, and will, find a cure for Type 1 diabetes eventually. But Type 1 diabetes represents only a small percentage of the total diabetic population. The epidemic of obesity, a major contributor to the development of Type 11 diabetes, has to be controlled as well.

As our new president takes office during the worst economic crisis since the Great Depression, the promise of universal healthcare will still be on many Americans minds as they are laid off, look for work or try to keep their current employment, even though it may offer no healthcare benefits. The enormous cost of implementing universal healthcare begs for cost containment, more efficient use of tax payer dollars, and focusing on disease prevention as a way to decrease our expenditures for chronic diseases. What a perfect opportunity for a progressive president to spend a few billion dollars in support of embryonic stem cell research that will yield an economic benefit worth many times it's cost.

For a president who will make history just by having been elected, imagine the footnote that can be added to his already monumental achievement by stating that he was responsible for the first true cure of a costly chronic disease simply by his support of embryonic stem cell research. With the legislation currently in place, sure seems like a short step in the right direction.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

President Barack Obama

Now I lay me down to sleep. I pray the Lord my soul to keep. And if I die before I wake, I pray the lord my soul to take.

That's the prayer my ex-wife taught to our daughters. We still say that prayer every night at bedtime. Now that the election is over, McCain has conceded and we have a new president elect, we should all pray. The next president is going to be faced with challenges not faced by any president since FDR and the great depression.

This is not simply an issue of race. Granted, the US has elected it's first black president, but if this were any other country in the world, the color of the elected official's skin would not have been an issue. Now that he is our president elect, he will be scrutinized more closely than any other. Again because the color of his skin and not the tough job that lies ahead. He inherits a mess that any president would have a hard time trying to manage. Let's cut the guy a break from the racial issue, give him the benefit of the doubt and see what he's made of.

I also realize that many blacks (African-Americans) will be holding high hopes that this president will pay special attention to the plight of his kind. But if he does , is he any better than any other president who may have ignored or paid special attention to a particular group or people? He would be placing a blemish on his accomplishment if he does. I hope blacks are not disappointed if he takes the high road and treats all of us the same. I think that is all that Martin Luther King, Jr. ever wanted. And all people, white and black, who sacrificed themselves for equality of any kind. Hopefully, this president will be able to do that for us without being condemned for it.

Congratulations, Mr. President.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Vote

It's that simple. No rants. No raves. If you can't act like a natural born citizen, raised in the US, reaping the benefits bestowed upon you by the greatest country in the world, well.... Act like an immigrant who has struggled to get here and attain citizenship. They are some of the most grateful citizens you will ever meet and probably the first in line to vote this morning.

GO VOTE. MAKE A DIFFERENCE.

Doc B

Enough Already!!!

I thought my last post was good enough to cover the barrage of advertising we are all being bombarded with, but I was wrong. If you recall, I explained that I don't typically use my home phone and prefer to use my cell. A lot of us are of a similar thought. Since I don't use it, I don't usually check for messages. If you know me, you call my cell. But, when I got home today I checked the phone and the caller ID and saw four missed calls since I left for work this morning. One of them was my mother, and she did try my cell, and we had a nice conversation. The others I didn't recognize so I decided to check the messages to see if there was anything important.

I dialed into my voicemail and the very pleasant but monotone, female, computer generated voice asked for my password. I entered it obediently, like I always do and was told by my unsexy female friend that I had 16 unheard messages. 16!!!! I've never had so many messages, ever. Not even on my business line after I've been on vacation for a week. I punched #11 to get my messages and guess what?

Those sixteen messages were from Oct 28 until today. Of the 16 messages, 11 were political. Most were presidential calls. I even got one from Sarah Palin herself. I'd like to think she took the time to call me personally, but I'm pretty sure it was recorded. I got one of those calls from GW in 2004 too. Told my kids I was important and that the president was calling me directly to ask for my support. I even let them listen to the message. Boy were they impressed!

When you add the three that I received in rapid succession yesterday, that is a total of fourteen out of nineteen phone calls that were political advertisements. Twelve of the fourteen were related to the presidential election. How much more of this can we take? I am so fed up with the whole process that I can't imagine how each candidate's supporters must feel. After all of this is over, they'll all need a stiff drink, then go over into a corner somewhere and pass out for a few months. Actually, that sounds like a good idea right now.

When it's all said and done, more than 2 billion dollars will have been spent on this election. All of us have had our senses saturated, invaded, bombarded, abused, molested and violated by the most disgusting presidential advertising campaign to date. I hope that there is actually such a thing as true campaign finance reform that someone proposes in congress after the election. And someone will bring it up. Not because it is the right thing to do , but because Obama kicked McCain's butt raising money, giving him the most lopsided advertising blitz we have ever seen.

I just hope they add campaign robot calls to the no call list. Everything else I can ignore.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Obama's Money is Buying My Misery; Enough Already!

Earlier one of my posts dealt with the amount of money each of the candidates and their respective parties had raised for the 2008 election year. Disgusting to say the least. As of the date of this post, the airwaves, and our senses, are being saturated with political advertising, local and national, Obama and McCain. Most I can tolerate, but they got on my last nerve tonight.

Southwest Ohio is experiencing an unusual warm stretch the weekend just before the election. Temperatures hovered near teh low 70's and not a drop of rain on the horizon. I took this opportunity to work outside and actually went for a ride on my motorcycle (with a helmet) dressed only in t-shirt and jeans. The slight nip in the air was perfect. Upon arriving home I decided that this was an ideal day to take advantage of the warm weather and get another day of use out of my grill. I thawed out a nice ribeye steak that I had bought on sale earlier last week. Just as I was ready to sit down and enjoy my perfectly grilled steak.....

Of course the phone had to ring. I, like many people, use my cell phone as my primary phone. Anyone who knows me, knows to try my cell phone first. That means that if my home phone rings, either my cell phone isn't working (everyone tries my home number as a back up to my cell) or I don't know you. The offender who was interrupting my dinner today fell into teh latter category.

Caller ID has allowed us to pre-screen our phone calls so we can pick and choose who we wish to talk to, before we even answer the phone. We are so accustomed to it on our cell phones that we can give a name, instead of just their number, to our frequent callers. The name shows up on the screen and again, we can decide whether or not to answer. Just like my home phone, if I don't know the number , I don't answer.

Back to dinner. I let the phone ring until it went to voicemail and then checked to see who it was. The toll free number, 877-622-6264, was in the caller ID display, but without any additional information. Since they left no message, I ignored it and sat down to enjoy my hot, juicy, delicious steak. Not more than 2 bites into my meal, the phone rang again. Guess what? Same number again. This time I answered. I was sure it was some sales call (despite being on the infamous "No Call" list) invading my Saturday evening dinner time and was ready to tear into them and say "No thank you. Please don't call me again and take me off your list". As soon as I answered and said "Hello" an obviously recorded voice began speaking about Barack Obama! I screamed into the phone; "Stop it!! Leave me alone!!" and hung up.

I took two slow deep breaths trying to calm down and relax before taking the much anticipated next bite of my steak. Proper digestion deserves a calm and relaxed consumer of a wonderfully prepared meal. As I relaxed and began enjoying my steak, you will never believe what happened. You guessed it! Another call from the same 877 number. This time I ignored it again and didn't allow it to ruin the moment. I finished my steak (which I enjoyed immensely despite the Obama invasion into my meal time), then headed straight for my computer after cleaning my dishes.

So this is what the candidates are doing with all of the money they've collected? Harassing people at home, on the weekend, at dinner time, who are on the "No Call" list, not once but three times in rapid fire succession! And since Obama has more money than McCain, he is a much bigger offender. I think that this individual, direct to consumer type of advertising, may have the exact opposite effect than what the purveyors of this nuisance wanted. I was so frustrated and angry at this unwanted intrusion into my home, that it left me with an overall bad feeling for Obama.

I'm being bombarded with political advertising in my email, on my TV and radio, placards in yards and on roadsides, and billboards. But the main difference is that these are passive forms of advertising. I can choose to ignore them. They do not require my participation in any way shape or form. By calling my home they have come uninvited, invading my castle and making me an unwitting participant in this year's obnoxious orgy of the gluttony that has become a self-righteous, self serving greed of political spending.

Exactly what is the ulterior motive that would drive the candidiates to be so obnoxious, so disgusting, so political that they would sacrifice friends, family, reputation and dignity? If these are the qualities of our candidates, just what do you think they would say in their adds and to the American public just to get elected?

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Ethics in Healthcare

I have a very unique and privileged position in the current healthcare environment. Not only am I blessed to be a clinician (see patients), I have the additional honor of being involved in the administrative aspect of medicine as well. Because of my unique position, I hold many committee memberships. One of those positions added recently was for my hospital's ethics committee.

One topic discussed in most committees is the upcoming flu season. People don't realize the planning that hospitals endure in preparation for a possible pandemic. The need for intensive care unit beds, ventilators, additional staffing requirements, etc., are discussed as much as the joint chiefs of staff may discuss their available resources for an upcoming defensive or offensive deployment.

Our recent discussion concerned the need for personnel in case of a disaster, including a flu pandemic (we are due for a true pandemic-not a media generated hysterical fake pandemic, but a real one). Our discussion centered on the response of the hospital's staff, nursing, ancillary and even physicians. I was always under the impression that we always show up for work, regardless of our own states of health. In one of my earlier posts I even vented when I had to get up during a "snow emergency" and go to work when everyone else, including civil servant emergency personnel, stayed at home.

Our discussion turned into a real eye-opener for me. My take on the whole issue was that if my family were safe and didn't need my immediate attention, I would be at the hospital caring for patients and staff. I've always wanted everyone who knows me to think of me as a regular person first, then as a physician. Being a physician was always what I did, not who I was. After our discussion, I doubt there are many people, much less physicians and healthcare personnel, who will be there when we need them.

Most members of the committee (all had been members long before me and had this discussion before) had a sense that a significant percentage of personnel would stay at home in the event of a disaster (tornado, flood, terrorist attack, flu pandemic, etc.). They have even gone so far as to plan for daycare services for employees to encourage them to come to the hospital.

The trend of non response is a direct reflection of the younger, more selfish, generation. Physicians my age and older would respond without hesitation. We are also the physicians who used to work 80-100 hours per week as residents learning to take care of patients. We were overwhelmed on a daily basis and learned to deal with the stress that comes with it. We learned to triage patients over the phone because we had seen SO MANY patients during our short careers that it became second nature to us. Common things occur commonly, and we saw many of them. Because of the large volume of patients, we also got to see many of the uncommon things first hand, not hear about them from someone else the next day. This hard work gave all of us the work ethic that most people attribute to their older physicians.

The newer , younger, physicians are the ones who, as residents, had mandated limited working hours, scheduled time off and limits on the number of patients they could care for. More technology and fewer patients means less "hands on" direct patient care and experience. These physicians have become so accustomed to the reduced working hours that they are all looking for 40 hour per week jobs, 9-5, no call and no weekends. Boy, wouldn't that be nice?? And you know what? There is such a shortage of doctors in some areas, that some of these physicians are getting exactly what they want.

The work ethic of your parent's doc, or maybe your own, is a thing of the past and will be dead and completely gone when I and mine retire. So when the pandemics or disasters hit, don't be surprised if that new young doc who just graduated and moved into your neighborhood isn't huddled at home with you.


Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Our Tax Dollars at Work?

Sorry, but today no healthcare related rant. Too much other juicy stuff going on that have made healthcare, the once hot topic, take a backseat. The most recent issues are certainly related around the economy and the resultant collapse of the credit markets and the banking system. Mortgage backed securities have become the junk bonds of the 21st century, much like Michael Milliken of the 1980's.

The governement's (Bush) response to the crisis was at first to ignore that there was a problem. Then, when it got smacked in the face with it, a 700 Billion dollar bailout with taxpayer money to stem the fear of a total collapse of the US markets; the likes of which hadn't been seen for decades, or maybe even since the great depression. An economy in shambles. National debt at it's highest ever and a deficit that will be an estimated 700 Billion to 1 Trillion dollars next year. What an inheritance for the the next president to assume and a great gift to leave our children and grandchildren.

Among all of this is the presidential election. The candidates are making their final push to sway and attract voters. TV, radio and print adds are flying with wanton abandon. Unsolicited telephone calls invade my home, and cell phone, on an almost daily basis. Emails come daily filling up my inbox with garbage I don't want to see or read. How do they pay for all of this?

Just out in the last few days are the latest figures for both candidates' fundraising efforts over the past several weeks. Obama, who opted out of the taxpayer funded campaign program, has raised nearly 150 Million dollars from donations for the Sep/Oct period and along with party funding, has nearly 200 Million dollars at his disposal leading up to the election. McCain, on the other hand, opted for public taxpayer money and is limited to 84 Million from now through election day. Both candidates still have their respective parties funding some of their advertising. Obama's total raised by his campaign for this election totals more than 600 Million, while McCain raised just 240 Million.

With the kind of money these guys are raising, I think that to use public funds, when it could be used in other areas, is fiscally irresponsible. I know that camapign finance reform was designed to reduce the campaign contributions from large influential contributors and therefore reduce fraud and corruption, but they have gone from one extreme to another. And, who really thinks that our politicians are any less corrupt than they used to be?

Considering the amount of money raised by each party, the disparity in fundraising between Obama and McCain, how can anyone say the election wasn't "bought"? Obama raised so much money after the convention, he was able to buy up every minute of available airtime on all the networks prior to the election. Even if McCain had raised more money, he would have had no real effective outlets where he could be purchasing advertising time. No one will ever doubt that Obama ran a very military precise campaign but without funds it never would have happened. Elections can still be bought despite campaign reforms.

I believe it should not be up to the taxpayers to fund the presidential elections. The individual candidates should be responsible for their own funding. But, that funding should not be a result of a popularity contest or the financial capability of their constituency. The federal governement's role in this process should be one of oversight. Each candidate must have access to the same resources as the other. A cap on the amount spent should be instituted so that one candididate does not simply outspend or "out advertise" their opponent. Equal spending would therefore make the candidates concentrate on the content of their messages instead of the volume of their messages. We all have the same feeling this year; just get it over with.

This year's election will be determined by the amount of money spent on the election. It is yet to be seen if that turns out to be the right choice.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Aletrnative Healthcare Proposal-AMA Style

Finally, something else to talk about than the same 'ol Republican/Democratic proposals. The American Medical Association has expanded it's original recommendations for universal healthcare to the current "three pillar" approach. Overall, conceptually, it seems less painful than some of the political proposals, but has some not so pleasing aspects itself. You can read a synopsis of the plan here.

The AMA's three pillar approach is; 1. helping people buy health insurance through tax credits or vouchers; 2 choice for individuals and families in what health plan to join; 3 regulating markets and protecting high-risk patients. I don't think anyone has an issue with numbers two and three of the three pillared approach. What is somewhat different is their proposal for how to pay for the tax credits and/or vouchers.

Their idea is to eliminate or markedly reduce the tax benefit that employers and or employees receive by not having the employer based healthcare benefits taxed. Most employers who provide health insurance are able to deduct the cost of insurance as a business expense, and therefore, pay no tax on them. Employees are not usually taxed for those benefits either. McCain's plan opted to tax the employers. The AMA wants to tax the employees.

The AMA idea is to tax all, or a portion down to a minimum allowable, of the healthcare benefits to recoup the estimated 125 Billion in lost tax revenue. Those additional taxes would be used to pay for, or subsidize, low income or uninsured persons though tax credits or vouchers. The credits or vouchers HAVE to be used for the purchase of health care benefits. In essence, it amounts to another entitlement program through a redistribution of "wealth".

Their thinking is that the highest income earners who receive the same employer-based health insurance benefit, receive the largest tax break since they are in a higher tax bracket. True, but only if those benefits are universally taxed for all recipients. They are not at the present time. This amounts to the same type of taxation and redistribution of wealth that occurs now. People of higher incomes are taxed at a higher rate. Those dollars are used to pay for the government funded entitlement programs that the higher income individuals will NEVER benefit from.

This is not a "government funded" or subsidized program. It is the creation of a new tax and the subsidy is coming from, on a percentage basis, the same taxpayers who are already providing a larger percentage of their income for entitlement programs. That is a perfect definition of a distribution of wealth.

I am all for a form of universal healthcare that takes care of all of us, including those who contribute no taxes into the government coffers. But, I do not think that the first place to look is in the pocket of the populous who are already paying their fair share of taxes. Why not look to the greed of the insurance companies or the horrible inefficiency and waste of government programs? Pay for it with the SAVINGS that can be wrung out of the current failed system, not by creating ANOTHER tax.

I'm tired of working the first 6 months of every year just to pay taxes. How about you?

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Democratic Healthcare is Obama Healthcare

Well, now that Obama has finally clinched the nomination without having to bargain with Hillary, we'll get to see what the campaign should have looked like over the past several months. McCain has had an easy trip so far since the two front running Democrats were fighting each other instead of their Republican opponent. Obama has a lot of ground to make up, but so does McCain.

The campaigns will need to move hard and fast to cover all of the pertinent issues before the big push leading up to their respective conventions. Both would like to have momentum going in and a be on fire coming out.

McCain has been relatively quiet over the past few months while Clinton and Obama beat each other up and, likely, split the Democratic party. Obama is now left with trying to reunite the party and energize them over the next few months. Clinton made a mistake by not conceding sooner and possibly using her delegates as bargaining chips. Now that Obama doesn't need Clinton's delegates, he doesn't need her either. Or does he?

Most likely Clinton and Obama will have to kiss and make up if Obama has any hope of truly uniting the party. Making peace means that Obama will have a better chance of keeping the Clinton voters in the Democrat's fold. Keep in mind that each of them performed well with different groups within their party. Combined thay would be a force that could easily beat McCain in November. Obama will have to find some way of appeasing Clinton but, I think, without offering her the VP spot. The post will have to be a juicy one and lots of face time at the convention.

I also think that the Democrats will combine Clinton and Obama's healthcare plans into a single plan. To be honest, they really weren't that much different to begin with. Clinton wanted mandatory participation and Obama mandatory coverage for children. Either there is some form of mandatory coverage and some choice for all participants. I still think they're all going about it the wrong way. As long as profit is a motivating factor, greed and corruption will be an inevitable component of the program. But, the government can't run an efficient program either.

It appears we'll have to take the lesser of two evils. But which one is less evil?

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Healthcare Crisis

Been way too long again, but no one is saying anything of much value. What has been occurring more and more often is the withering away of your health insurance benefits. With every renewal period that passes, employers are faced with higher and higher premiums. In order to make sure that they continue to provide health insurance coverage to their employees, employers are faced with tough decisions. And the decisions they have to make amount to the "lesser of evils".

In any business, for profit or not for profit, the bottom line is the same. "Do we have enough money to pay our expenses". Next to payroll, health insurance is the next largest employee related expense, even more than an employers matching Social Security and Medicare taxes. It goes without saying that of those three expenses, health insurance is the only variable at their discretion to change (unless you would like your employer to fire you).

At renewal time, health insurance companies present the "new" premiums for the employees. Invariably, the rates almost always go up. Often times, insurers will offer a product that is slightly cheaper than the product up for renewal. Only problem is that the slightly cheaper product offers less coverage; higher deductibles, highercopays , reduced drug coverage, fewer covered services, etc. In essences it's the same as when the coffee companies reduced the size of a can of coffee but kept the price the same. Who do they think they're kidding?

Many employers have the same health insurance coverage as their employees. I was at a gathering where I met an entrepreneur. He and his partner have been in business for 15 years and have been doing quite well, as small businesses go. After 15 years with Anthem BC/BS, and no catastrophic illness in their group, they had an employee with a family member who battled and thankfully won, her fight with breast cancer. Unfortunately after paying over 3.5 million in premiums over the years (I'm being kind-the actual calculation is $800/month per employee X 30 employees X 15 years), they were given a renewal premium that the small company could not afford. The company began looking at other insurers for affordable health insurance coverage and were surprised to find that their "group" was uninsurable for some carriers. They were able to find coverage but with reduced benefits and higher deductibles and copays. The owners have the same coverage as their employees. The company is also considering having the employees pay a portion of their premium. That is something the company has never done in the past and never anticipated asking.

My own group has faced the same issue but without the catastrophic illness. For the first time in our existence, we'll be asking employees to pay a portion of their premium. Costs to employers continue to increase, employees are asked to pay more and more out of pocket, hospitals and physicians are reimbursed less and less, but the insurance companies still find a way to make a profit.

The next time you buy a one "pound" can of coffee (it's actually 13 oz), remember how upset you were when you found out you were paying the same money for less coffee, but the coffee companies were still making the same profit. It's so ingrained in society that many of our food items have been reduced in the same way. We just accept it now. Only difference between healthcare and coffee is that you can choose not to drink coffee. You can't choose not to get sick.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it

Healthcare Recession

Well, it's been quite awhile since my last post. To be perfectly
honest, there hasn't been a whole lot to talk about. Since the last
round of Democratic primaries and the debate, even the candidates
haven't been giving healthcare much lip service. But, thankfully, Hillary came through for us.

She has been recounting a story of a young pregnant woman who was
supposedly denied care, and later died. The story, which you can read
here, states that as a pregnant uninsured patient, she presented herself for care at the ED but was told she needed to pay $100 dollars first. Depending on the version of the story you hear, somehow she was able to be seen and "billed" for the $100.

After being seen in the ED she was told they couldn't help her but gave her a referral for outpatient follow up. The physician's office also refused care because of inability to pay. She later presented as an emergency case where her child was stillborn. She later died of complication of her pregnancy and childbirth.

First and foremost, if you read my previous blogs, there IS absolutely Universal Healthcarein the US. The Emergency Room may not be the best or most efficient place to receive that care, but it is FREE to anyone who presents themselves to the ED with NO ability to pay.

The Emergency Medical Treatment and Active Labor Act (EMTLA) is a Federal law that requires a hospital's Emergency Room to evaluate and treat anyone presenting with an emergency condition, regardless of their ability to pay. It is that ER's responsibility to evaluate any person who presents to the ER for the presence of an emergency medical condition. If needed, the patient must be admitted for treatment of that condition, or stabilized and transferred to another facility that can provide the necessary care. Failure to comply with the law could mean criminal charges, fines or being barred from participating in the Medicare and Medicaid programs, combined the largest insurers in the US.

Second; the woman in question DID have insurance and was seen and treated
appropriately. She had been receiving prenatal care prior to her entering the hospital. Unfortunately, both she and her child died. The exact details aren't available, likely due to HIPPA.

Certainly is a shame that politicians have to take a tragic story, place their own "spin" on it and try to use it for their own personal gain. Shameful. And, after learning that the story was not only incorrect but potentially damaging to the hospital and doctors ivolved, do you think she was at least classy enough to apologize or retract her statements? NO. Look here. But then again, she's done that in the past, hasn't she?


My opinion is free.
Advice is worth exactly what you pay for it.

Doc B

Helthcare and Politics

My state medical association called me again today. They wanted to know if they could entice me to rejoin the association, as they were preparing to "battle" the insurance companies. You see, I had let my membership lapse some time ago. They were offering all sorts of free gifts, aimed at the practicing physician; clinical tools to assist with patient care, programs designed for patient education and the like.

I kindly declined and he asked if I could explain my reason for not wanting to rejoin. I explained that as a practicing physician, I was more concerned with the care of my patients than I was about the politics. The medical association has been "battling" someone for years and never really won any of those battles on their own. Not a single issue was brought by them on behalf of the physicin membership and carried through to a successful, promised conclusion.

More money thrown at politicians to get their vote or sway their opinion. Unfortunately, no one feels sorry for the physicians. The public doesn't care about issues like fair compensation, malpractice rates, frivolous lawsuits, sacrifices made during education and training, or missed opportunities with family. It's hard to be a politician and side with the physicians in the face of their constituency. Not a very popular thing to do at all.

We recently had a level III snow emergency. That means that NO ONE was allowed on the roads except for emergency personnel and anyone caught out could be arrested. But guess who had to get up to go to work that day while everyone else, including some of the snow plow drivers, stayed in bed; me. Again.

On my way in I was thinking that on a day like that physicians, nurses, patient care assistants, x-ray technicians, paramedics, policeman, and the occassional snow plow driver, were all on our way to work worried more about being on time than about our own safety. I wonder how many people, aside from our own family and friends, were worried about us or appreciated the effort we were making to keep everyone safe and healthy. Not many I bet.

So when the medical association or PAC's come calling, I don't want to hear it. If we (the people I mentioned above) can't get the respect and appreciation of the people we sacrifice ourselves to take care of, what the hell do I care if the politicians get more of my money to try to convince a bunch of people that don't give a damn in the first place.

Go back to bed. We'll take care of everything for you, just like we always do.

Doc B.

My opinion is free.
Advice is worth exactly what you pay for it.

Healthcare Debate; Now What?

Since my last post I have heard back from 2 out of 3 of the candidates. But not about healthcare. What I received were email after email regarding the same old rhetoric that their faithful are subjected to on a daily basis. BORING.

I should have known better than to contact them electronically. For the number of emails I received, they could have at least personalized one and addressed the question I asked. Instead I'm now on their mailing list.

Obama and Clinton are both great users of the electronic medium, but Obama more so than Clinton. McCain didn't even have the decency to harass me with spam email. What's up with that? I think he should irritate me at least as much as the Democrats! Stand up man. Be an equal opportunity offender!

Meanwhile I wait like everyone else. Any remaining debates will be more of the same with no substance and not much new to discuss. They are all going to sound like their radio and TV adds, going in one ear and out the other. I can hear the drone of their voices now... I can't wait for the "commercial interruption".

We may have to wait until someone is elected before we get any details about universal healthcare. Obama did promise to have something in place "by the end of his first term". I think that's optimistic, given the fact we haven't heard any of the details. And probably because they don't know what the details are yet themselves.

Zzzzzzzzz

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Universal Healthcare; Button, button, who's got the button?

After the debate, I decided that there really wasn't enough information in each of the candidates posted healthcare plans to really formulate an accurate assessment of them. So, I decided to try to contact each candidate through their websites and asked specifically for additional written information or, better yet, a conversation with a person who is "in the know" about their respective healthcare plans.

I received an automated response from Clinton and Obama with the usual dribble about being so busy because of all the emails and support they receive that they can't respond to every email personally. But the emails were able to direct me to links that informed me about how to contribute to their campaign, become a registered member of their team or how to find more information about them (but not about healthcare).

Interestingly, McCain didn't even respond with an automated email. I guess he's feeling so comfortable being unopposed on the Republican front that he doesn't need any more help.

Anyway. None of them seem willing to help a poor helpless healthcare provider figure out how their individual healthcare plans are supposed to work. If they can't explain it to me and I can't figure it out on my own, how the heck is anyone else going to be able to understand it?

We're all on our own. You'll all be expected to vote for a candidate when you have less than full disclosure about their positions. Sounds like another election of the lesser of evils. God help us.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Healthcare Post Debate

Oh boy, oh boy! What fun.

Obama and Clinton faced off this evening in Cleveland, Ohio during a debate at Cleveland State University. NBC carried the debate with Brian Williams and Tim Russert moderating.

And of course, I had to be blessed with the two of them discussing healthcare as the first issue of the evening. And of course, they went at it like we knew they would. According to Brian Williams, "14 minutes on one subject".

They both gave their opinions of each others' plans but nothing truly new was discussed. The basic differences between them are the same that we have all heard before. So, was there any benefit to the voter watching the debate? Probably not.

Again, the specifics or "nuts and bolts" of the plans are absent. I have a very hard time getting my hands around either of their plans. Not necessarily in terms of concept, but from a position of wanting to see HOW it will actually function. I want to see a step by step presentation of the plan. Take a family of four and show me how each of their "talking points" applies to them. SHOW ME how, and how quickly, their cost saving measures will be implemented. What improvements in quality, not just required documentation, can they show?

Eventually, some form of universal healthcare will be attempted, either by the Republicans or the Democrats. And, it doesn't really matter which plan gets implemented. The whole process is going to be slow, painful, confusing, expensive and inefficient. It will take YEARS before the smoke clears and we see what we really have or don't have.

Can you imagine the amount of effort it will take to make a change in an industry that is responsible for 16% of the GDP of the United States? Talk about a 400 pound gorilla.

Doc B
My opinion is free.
Advice is worth exactly what you pay for it.

Presidential Healthcare or Universal Healthcare?

Now that the Democratic nominee race has turned into more of the typical "not so nice" form of campaigning, we finally see the finer points of attack between Obama and Clinton. Mailers sent out by Obama's camp recently have blasted Clinton's healthcare plan where it hurts the most. In the voter's pockets. And Clinton is starting to look desperate and angry.

The mailer, which you can read here, focuses on the main point of contention betweenObama and Clinton; mandated coverage. While it may have appeared to be a plus when the plans were first announced, mandated coverage is now a weakness thatObama is exploiting with vigor.

Clinton's plan, as I addressed in an earlier post, mandates coverage regardless of ability to pay. Yes, it does promise tax credits, but unless tax credits have changed, you don't realize those credits until it's time to file your taxes. And you still need to wait to get your refund. For families living payday to payday, they won't be able to afford it when it's mandated and will always be a year behind, waiting for the credit and refund. It also doesn't say how much of a poor family's premium the credit will cover.

The mailer also mentions "fines" for those who don't purchase healthcare. So you make someone pay a fine who can't afford healthcare in the first place, and then take MORE money out of their pocket? Sounds like the Sheriff of Nottingham.

When the weakness of mandated coverage was first discovered, Clinton made an appearance on THIS WEEK WITH GEORGE STEPHANOPOLOUS. He repeatedly and directly asked her about mandated coverage, fines and garnishing of worker's wages. She skirted the whole issue initially, but George wouldn't give up. Finally she did admit that if necessary, "we will have an enforcement mechanism -- whether it's that (wage garnishing) or it's some other mechanism through the tax system or automatic enrollments". She looked very uncomfortable while she said it too. You can read excerpts from the interview;

http://www.cnsnews.com/ViewNation.asp?Page=/Nation/archive/200802/NAT20080204b.html

http://abcnews.go.com/ThisWeek/story?id=4235448

http://abcnews.go.com/Politics/wireStory?id=4235304

In the interview with George, Clinton seemed as if she really hadn't thought through the whole issue, referring to congress and that they may "have some ideas" on how to mandate coverage. When is the last time congress came up with a practical or simple solution to anything? By the time they come up with their complicated,irrational and expensive solution, we'll all be on Medicare.

Is the mailer factual? Absolutely. Does it make Clinton look bad? Absolutely. Is it smart to exploit someone's weakness during a battle? Absolutely. Point to Obama.

The real winner in this battle is actually George Bush. Don't hear much about the president with one of the lowest approval ratings in recent history anymore. He must be sooooooo happy.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Universal Healthcare: Promise of HIT reform

All of the candidates proposals so far have included an estimate of savings related to improving Health Information Technology. All of them are quoting the RAND report which was published in 2005 as a monograph.

The monograph is very detailed, 105 pages long and includes the calculations used to arrive at their conclusions. Interestingly though, they provided their estimate of savings BEFORE the estimated cost of implementation. Kinda like the cart before the horse. They also state that their estimates do not include any cost or savings related to the different systems being able to communicate patient information with one another across any distance. In other words, your doctor's office system can't talk to your pharmacy's system that can't talk to the hospital's system.

Many hospitals and physicians offices have already started implementing EMR's (Electronic Medical Records), at their own cost. Many have done so in response to HIPAA (Health Insurance Portability and Accountability Act) requirements. HIPAA dictates how health information transactions are to be carried out between applicable agencies/businesses (the standard) mostly for billing purposes.

The estimates for the cost of implementing an EMR quoted in the RAND report did not take into account any economies of scale, since most practices comprise 4 or fewer physicians. The estimate for implementation was $22,000 per physician as initial start up costs and $4,400 per physician for annual maintenance costs. Not an inexpensive project.

How do these figures compare to a real world practice? A moderate size specialty group in our communty is currently implementing an EMR for their practice. They have been planning the implementation for some time and took the effort to look at a large number of available products before making their final selection. Ultimately, the product they chose is costing each of the physicians in the group 30K-40K each, not including the loss of prductivity mentioned in the RAND report.

This group has 30+ physicians and physician extenders. If they are not able to achieve some measure of economies of scale, imagine the cost to a smaller practice. The often quoted RAND report likely needs to adjust it's figures, especially since the data in it is from 2004.

If we assume 30 physicians and an average cost of 35K per physician, then the total one time set up cost is $1,050,000 PLUS lost productivity during a training period (RAND estimates this loss at 15% of revenue). The annual cost of maintenance is 20% of the initial cost or $210,000 per year for this practice of thirty physicians. They have to make up that additional practice expense somehow, somewhere. How about charging more or seeing more people?

Can't charge more because insurance will only pay $XX for a certain visit/procedure, no matter what you charge and the providers' contracts prohibit them from charging the difference to you (except for deductibles and copays). Seeing more patients? The more patients you see, the less time you spend with each one, the fewer things you can address at a visit. Kind of goes against the whole idea of improving quality and quantity of care, doesn't it?

I don't know who the candidates think is going to be SAVING money by implementing the HIT improvements they are all promoting, but I doubt it is going to be the providers. At least Obama is willing to spend money for the HIT improvements, and his estimate of the cost to do so over a five year period seems reasonable.

As I've mentioned before, there is not going to be a no-cost, painless solution to the problem of healthcare and coverage for the under and uninsured. But, so far I'm not impressed that anyone has come up with a comprehensive, budget neutral, fair, quality driven program that meets the NEEDS, not wants, of the patient citizenship.


Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Healthcare-Barack Obama's Vision

Well, now that Super Tuesday is over, there's only one candidate to review; Barack Obama. McCain has effectively eliminated his Republican opponents, while Clinton and Obama have turned the Democratic race into a much needed slugfest.

Turning my attention to Obama's Healthcare plan gives me reason to think that all of the candidates are looking at hybrid systems. Shame. In the long run, they are not going to work. If the goal of universal healthcare is the goal, it shouldn't have to cost more than it does now. And it IS going to cost.

Obama's plan varies from some of the others in that there is no mandate for coverage. If you want to opt out and pay, you can. If you come in contact with the healthcare system, such as a hospitalization, you will be required to sign up. Seems reasonable. You can read Obama's entire plan here.

Things I like; universal care available, but not mandatory; sense of personal responsibility for your healthcare coverage; concentration on chronic disease management and disease prevention (same as everyone else); National Health Insurance Exchange and portability; guaranteed eligibility

Things I don't like; expanding SCHIP; protect against natural disasters?; government subsidies; small employers to contribute a percentage of payroll; Federal reinsurance; ensuring healthcare quality and transparency; promise of maplractice "reform" isn't really reform at all.

There are many common themes in the healthcare plans of all the candidates. Obama's seems to vary from Clinton's mainly with mandated vs voluntary coverage. I like the idea that people take responsibility for themselves in some form or fashion. Entitlement programs, to date, have created a subpopulation of our country that are so dependent on their government that they CANNOT care for themselves. It's time to wean them.

Obama's National Health Insurance Exchange is a good idea to promote some forms of competition, make shopping for insurance easier by offering comparisons (although, according to Obama, all plans have to offer similar benefits anyway-how much shopping will you need to do?), and provide a location for comparison's of qauilty-which I think is it's best benefit.

EXTREME care needs to be given to the assessment of quality as is currently being reported by such places as Healthgrades, some state government websites and being contemplated by Medicare. So far none of the reporting sites takes into account differences in documentation, severity of a patient's illness (some people with the same illness are just sicker than others), complications or comorbidities.

Documentation is the key to assessing true qaulity and outcomes. If the documentation comparing two hospitals, for instance, is exactly the same, then you could compare them with a greater expectation that the "grade" they are given is an accurate reflection of quality. Take Healthgrades as an expample. Compare two hospitals in your area and look up their grade for Stroke, Pneumonia or Myocardial Infarction (heart attack). Look at the ranking of the two hospitals, then expand those hospital's specific data. If the hospital with the lower ranking has a lower rate of mortality, then the issue is most likely poor documentation, not poor quality of care. But of course, that's not the perception that Healthgrades gives you.

Expanding SCHIP, or any Medicaid program without eliminating the waste in it is irresponsible. Looking back at an earlier post with the national healthcare data shows how expensive Medicaid and SCHIP are already. Not a very cost-effective way to provide care. And now the government is trying to contract out Medicaid in an attempt to develop a product comparable to Medicare Advantage, which Obama acknowledges contains a large amount of administrative waste. It also means that the new administrative overhead is NOT being spent on patients or the providers who care for them.

The plan as a whole will be more expensive. Employers will be expected to contribute a percentage of payroll towards coverage if they don't offer it as a benefit. The natural response to keep the employer "budget neutral" will be a reduction in wages. Federal subsidies just mean the government will be spending money on healthcare indirectly, but spend it nonetheless.

His promise of healthcare reform really doesn't address two important areas. First is tort reform. Our current system rewards attorneys for large settlements. That alone is a huge incentive for the attorneys to file frivolous suits in hopes of hitting the jackpot. Award caps or reasonable caps on attorney fees/charges would help to stem alot of that problem. No more contingency fees. If the case has merits, they'll take it anyway. also, states with caps have seen liability insurance rates decrease significantly.

Second, with regards to tort reform, is protection from prosecution if the providers have followed accepted best practice guidelines. Shit happens and not every death is preventable despite our best efforts. Why should someone be sued if they have provided the best care possible and followed accepted best practice guidelines?

Obama's plan also stinks of "Big Brother". The National Health Insurance Exchange is going to monitor quality, competition, pricing, monopoly, benefits offered, profit and premiums. Sounds a lot like a public service commission. Regulation does work to control cost but not to foster competition, which is the reason most industries were deregulated in the 1980's. Prices did increase, but each company did it's best to differentiate itself from the competition, either through innovation or products/services offered.

All in all, the big three have similar plans with some differences. Too bad all of them think that the government's involvement in a partnership with the insurance industry is a good idea. Insurance companies are greedy and the governement is wasteful and inefficient. What a combo.


Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Healthcare; John McCain's Way

John McCain gave some details regarding his healthcare plan at a speech in Iowa back in October. The entire speech can be read here. I didn't find a separate link on his website leading to a formal outline, so this is all we get.

Things I liked about McCain's "proposal"; coverage for all; tort reform; idea of coordinated care; emphasis on personal responsibility for our health and prevention of chronic diseases;

Things I didn't like; health benefits instead paid to employees as wages then give them a tax credit; emphasis on payment for "quality" without defining how to measure it or account for complications or comorbid diseases; almost no emphasis on reducing waste in government run programs; coordinated care(more detail for the contradiction below);

Overall, McCain's approach is from a conservative point of view that doesn't disrupt the "staus quo" very much. It seems to focus more on an oversight role to ensure the quality and accountability he repeats over and over again. Corporate greed and profit certainly aren't mentioned as places to trim fat from healthcare expenditures.

Notes;

1. Like Hillary, McCain is suggesting that instaed of employer funded insurance benefits, the employee should be paid wages, have the wages taxed and then get a tax credit from the government. For low wage earners this will seem like they hit the lottery. Receiving an additional 6-8K per year as wages, a low tax rate AND a tax credit, who wouldn't vote for that? As income increases, the tax rates increase and a smaller portion of those wages come to you. Don't forget that you also pay 7.625% (along with your employer's matching contribution) as Medicare and Social Security Tax. And you still have to buy your health insurance. Again the less you make the better off you are. Another form of redistributing income, except now the government wants it's share though increased taxation.

2. Paying for quality is not a new concept. As I mentioned in the Hillary post, Medicare 646 was designed to look into better ways to provide quality, explore the benefits of paying for chronic disease management and also, disease prevention. Insurance companies are doing this already. The government may be ready to participate AFTER they review the results of their 5 year study that won't conclude until 2012.

3. Coordinated care IS a great concept. Care must be taken to make sure that there can be some variability based on a patient's "severity of illness" and their complicating or comorbid conditions. For example, it would cost MUCH less to care for a 55 year old female, who only has high cholesterol and needs cardiac bypass surgery than it would be to take care of a frail, 68 year old male with high blood pressure, diabetes, high cholesterol, chronic kidney disease, anemia, tobacco use and emphysema, who needs the same bypass. It may sound extreme, but the male patient is pretty typical for someone with heart disease, more so than a 55 year old female.

4. Medicare has started looking at "severity of illness scores", physician's practice patterns in regards to specific diseases comparing them to their colleagues and resource utilization. The problem is that Medicare is only looking at the claims that come to them with specific diagnoses. They are not fully taking into account the patient's complicating and comorbid conditions. The Inspector General has recommended that Medicare use all of this data as a measure of quality and payment for that quality, but only after the data reports what it is supposed to. They aren't there yet.

5. Medicare, nor anyone else for that matter, should have to pay for medical errors, but at what point does an action constitute an "error"? And what is the definition of an error? In most people's minds an error is anything that doesn't go as expected. Dictionary.com also defines error as "a wrong action attributable to bad judgment or ignorance or inattention". I think this is the definition of error we should use for healthcare. If granny is in the hospital, gets out of bed to go to the bathroom, and in her usual, at home, confused state, falls and breaks a hip, does that constitute an error? Medicare thinks so and won't pay for the treatment of her broken hip. And Medicare won't allow granny to be restrained, even if it is for her protection. Perhaps the presidential candidates should all spend a week in a hospital watching all the grannies, then when they fall, the error can be theirs.

Overall I think McCain's healthcare plan is a less painful alternative to Hillary's. But McCain doesn't give us enough detail, isn't addressing government waste and inefficiency in the Medicare and Medicaid programs, neglected to speak to insurance company profiteering, forgot to tell you about the additional taxation and forgot to mention how much this thing will cost.

Sounded good in the speech though.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Healthcare: Hilliary Clinton Style

I chose Hilliary as the first presidential candidate to review because she has tried and failed already during Bill's first term as president. Let's see if anything has really changed.

Hillary's Healthcare plan can be viewed here for the cliff note version and the entire plan here, in pdf format.

Things I like about Hillary's plan; guaranteed coverage, coverage for everyone and eliminating insurance company discrimination regarding whom to insure, whether to insure, and rate adjustments for higher risk patients.

Things I don't like; everything else.

The lengthly, and often redundant, pdf version of her health plan contains a lot of rhetoric aimed at appeasing and attracting the simple-minded potential voter. Some key points to ponder;

1. Eliminating the employer exclusion for health insurance means that your employer will no longer be able to write off their cost of your health insurance premium as a business expense. Instead it will be included as taxable income to YOU. Of course, they'll give a TAX CREDIT, to offset the extra tax you're paying already.

2. Medicare 646 is a study commissioned by CMS (Medicare) to find more efficient ways to provide care. Here is the link. What Hillary is proposing as HER idea was actually put into place in 2005. Final applications were accepted Sept of 2006. Implementation of the study was to begin in 2007 and continue for 5 years. The object of the study is improving efficiency in government funded programs, not private. Most private insurance companies and providers are already implementing many, if not ALL, of the recommendation made by Hillary and still under study by CMS.

3. Hillary claims significant savings from preventative services and chronic disease management. But, Medciare stops paying for annual pap smears and mammograms for eligible Medicare women because those women are "too old" to have breast or cervical cancer. Breast cancer is still the #2 killer for women behind lung cancer. Most insurance companies and hospitals have already instituted disease specific management protocols because they have realized their fianancial rewards. The government funded programs have not.

4. Health insurance choice? If I were to choose what plan to accept; mine, federal employees or Medicare, I'd choose federal. They have the best coverage at the lowest cost, and we, as taxpayers, are paying for EVERY penny of it, even the amount the members of Congress pay "out of pocket" (we pay their salries too). Here is a link to their plans and premiums. See how they compare to yours.

5. Why opt for the most expensive plans (see earlier post for cost per person comparison)?. Expanding the already expensive and inefficient Medicaid program is not the answer. Neither is choosing a Medicare-like insurance option.

Be careful what you ask for, you just might get it. But, don't let someone sell you a bill of goods just because it sounds good on the surface. There is no easy fix for any problem that consumes 16% of the US GDP. It'll take a lot of time, compromise, sacrifice and pain to create something we can all live with. Let's have the patience to tell all the candidates to look before we leap.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Presidentail Candidates Healthcare Proposals; Baseline data

In order to make sure we're all playing on a level field and that none of the candidates try to play with the data, I am including the 2006 Census report for Historical Health Insurance Tables. This is the data that everyone is quoting that states 47 million Americans are without health insurance coverage. What no one is reporting is how our healthcare dollars are being consumed among the various groups. Let's see if we can shed a little light on the subject.

Everything I report here is available from the US Census Bureau website, the CIA Factbook and a link to an article by a Canadian physician with his views on Universal Healthcare run by the government.

Total dollars spent on healthcare for 2006 $2.105 TRILLION

Population of the US in 2006 296.8 Million

Average cost person for healthcare $6,700

Private Pay $1.1352 Trillion (51% of Total)
(private insurance, out of pocket, etc.)

Insurance costs $723.4 Billion
Out of Pocket expenses (consumer) $256.5 Billion
Other (non-government) $155.3 Billion

Population covered by Private monies 201.7 Million (67% of general pop)

Average cost per covered person $5,628

Government Pay $970.3 Billion (45% of total)

Medicare $401.3 Billion

Population covered by Medicare 40.3 Million (13.6% of pop)

Average cost per person Medicare $9,939

Medicaid (Federal, State and SCHIP) $569.1 Billion

Population covered by Medicaid 38.3 Million (12.9% of pop)

Average cost per person Medicaid $14,859

Notes:

If there are inefficiencies inherent in the "system", wouldn't it make sense to go after the apparently most inefficient one (cost/person) first?

The government programs spend much more per person than do any of the private programs, AND cover less people.

The uninsured are actually covered by the private sector because as they seek healthcare, they may receive a bill from a hospital or physician, but they won't or can't pay it, so it gets written off as bad debt. The government has a fixed payment system, there is NO WAY for private entities to recoup any of these costs except through private, paying customers (cost shifting).

If you recalculate the cost per person for the private sector and ADD in the uninsured, the actual cost per person is $4,564.

ALL government programs are paid for with your tax dollars. Expansion of any government program will simply increase taxes or decrease deductions.

An article by a Canadian physician, Dr. David Gratzer, looks at the Canadian style of National healthcare from his perspective as a patient and as a provider. I recommend it as required reading for anyone considering letting the government run anything. Find it here.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Healthcare; The presidential candidate's proposals

Over the next several posts, I'll be reviewing and digesting the front runner's positions and proposals on healthcare. All of the candidates have one but the only ones discussed here will be those that are easily available to everyone on a particular candidates website.

Most of them have broached the idea of healthcare reform and at times have used it as a topic of debate. No one has given details, at least in the debates or press conferences, how it will be paid for. As I mentioned in an earlier post, any hybrid program is doomed to failure because of corporate greed on one hand vs government inefficiency on the other.

The only way a hybrid program would conceivably work is if there were strict regulation, much like there is in the utilities industry. Many of you may recall when the oil and airline industries were regulated and what happened to prices AFTER deregulation. The reason for the regulation in those industries at the time was because of a small number of corporation having control of a high demand product or service, an oligopoly.

The insurance industry is much like that today. While there are many smaller firms offering health insurance, the bigger players still have the lion's share of the market. The smaller outfits also can't offer comparable benefits to as many providers because many providers don't participate in smaller plans. It's simply not worth their time.

So, if the candidates are truly committed to healthcare reform that provides good benefits at a reasonable cost, I'm ready to listen. But, I want details.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Your Doctor as Social Worker? Or "beam me up Scotty, there's no intelligent life here".

Most people assume that with the "MD" after your name it garners some form of respect, just because of the degree and expertise, the job you have to do. Maybe it did "in the day", but certainly no longer. Physicians are looked on with contempt; looked at as an easy target for a frivolous lawsuit; spends as much time pushing paper and doing social work as caring for patients. The social work aspect of practice is increasing at an alarming rate and is directly proportional to the change in the demographics of our hospital patient population. In other words, the poorer the patient, the more services have to be arranged for them after discharge.

Don't get me wrong. I don't mind helping people who need help, but the people who utilize these other services the most are the ones who "abuse" the services always. Take for example a member of the working poor who simply doesn't have health insurance. This type of patient worries about how long they will be in the hospital because of the hospital bill. They are anxious to get better so they can be discharged sooner. They are also the ones that ask "how much" their prescriptions cost and will ask if cheaper alternatives are available.

On the other hand we have the hard core professional patients. These are the ones with repeated admissions for the same problem. They hop from ED to ED and frequently get multiple prescriptions from several different doctors for, guess what, narcotics. They have developed their own specialized complaint that is difficult to disprove by exam or by laboratory study. If the ED doc believes the story or has never seen them before, they get admitted.

The admission isn't the bad part. It's the discharge. From the date they are admitted until discharge, and sometimes long afterward, they are consuming vast amounts of resources.

Here are some of my favorites;

A young woman admitted with stomach pain and maybe diarrhea, who likely has a mild case of stomach flu. Most of us would take care of it at home with fluids, acetaminophen and rest. She, of course needs large amounts of narcotics to control a pain we can't locate with any exam or test. No diarrhea during her stay in the hospital, either. Appetite seemed OK and she was out of her room smoking whenever someone was looking for her. After several days, she was discharged but refused to leave saying she had no where to go. We were amazed. She had a place when she was admitted.

The answer, of course, was simple but new to me. She and her mother lived together. During her hospital stay, the patient's boyfriend and mother decided to "hook up". Since mom thought it would create a problem with all of them living together, she decided to kick her daughter out, leaving her homeless. Needless to say, our social worker had to put her thinking cap on. Eventually the patient was given a cab voucher, a voucher for prescriptions and, with the assistance of the social worker, located a family member willing to take her in.

My best stories are the alcoholics. They party 24/7 with reckless abandon. That is until they truly get sick or run out of money. One such person came to us after having a case of the stomach flu of the month. His routine was to drink 12-18 beers per day, a few Long Island Iced Teas, a bottle of wine and whatever else he could get his hands on. During sporting events, he would have 7-8 beers at the game PLUS his usual at home. Where the hell do these guys get the money?

His family brought him in because he wasn't acting right. After talking to the family, I knew right away the guy was going through withdrawal. To be perfectly honest, I wish they had brought him in sooner. It would have been easier and safer to give him a drink and send him home than to let him detox and go through DT's. But that wasn't to be. He did go through withdrawal and he did go through DT's; for three weeks. He laid in our ICU, nearly unconscious, for three weeks. All because of alcohol. We are not a detox or treatment facility.

When he woke up, we sent him home because he refused outpatient treatment and didn't even want any information for any treatment programs. He'll be back.

Another of our alcoholic friends comes in often. Sometimes for falling down, sometimes for pain and sometimes just because he' s drunk and has no where else to go. One such night he came in sooooo inebriated, that after several hours of "sleep" he was still too dunk to go home. So, the ED admitted him. When he finally woke up, I discharged him. But before he would leave, he wanted another meal, another shower, a new change of clothes and new shoes. The hospital gave it to him and then we gave him a a cab voucher to get home. Should've given him the cab voucher in the first place.

One of our most infamous frequent fliers is a diabetic aged 20 years. She's had her diabetes long enough to know how to take care of the basics. That means that she should be able to keep herself out of the hospital. She splits her time between us and another hospital across town. She'll spend a few days with us, stay out 1-2 days then spend a few days with them. The cycle repeats. She comes in with Diabetic Ketoacidosis, the most severe and critical illness a Type I diabetic can have next to acute hypoglycemia (low blood sugar). It is always serious and often life threatening. She knows full well that she isn't taking her insulin like she's supposed to. Soon she's going to push it too far and die. She doesn't seem to care.

She always does well while she's with us meaning she's not the "brittle" diabetic people hear of. We always go over her insulin regimen, what to do when her sugars are high and refill all of her medicines when she's discharged. She also gets vouchers to get her meds refilled at the pharmacy. As often as she's gotten vouchers from us, she'll accumulate a year's supply in about 3 months.

The best of all, and the predictor of things to come, was a young man who presented to the ED with belly pain. He had fever, white count (sign of infection), nausea and right lower quadrant pain. First thing we all think of is appendicitis.The ED physician ordered a CAT scan which the radiologist read as acute appendicitis. This is a surgical diagnosis and he needed an operation. The surgeon on call came in, examined the patient, looked at the CAT scan and then went to talk to the young man's mother.

He introduced himself, explained what his exam, blood work and CAT scan showed, then proceeded to explain that her son needed surgery, an appendectomy. Her response was "You're wrong and I'm going to sue you!"

That doctor finished the surgery then took himself off of the call schedule for the ED. Another pair of skilled hands has bitten the dust.

Their stories differ a little but the theme is the same. I did this to myself; yes I'm still going to smoke; no I'm not taking my meds like I'm supposed to; no I'm not going to see the doctor you found for me;I came by ambulance, can I have a ride home; can I get my meds for free; can I stay another day; no I want the stronger pain pills; well, Dr. X will give them to me, why won't you; I'm going to sue.

And you all wonder why healthcare is in crisis; why more and more doctors are looking for a way out; why there are fewer applicants to Medical School; why costs are skyrocketing; why liability insurance premiums are outrageous?

Take a good look around. The finger of responsibility needs to be pointing back at the person looking in the mirror. The gravy train needs to be stopped before the whole thing derails.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

How do I fnd a good Family Doctor?

Working as a Hospitalist means that I have no outpatient practice. Many of my patients ask me near the end of their hospital stay if I can be their Family Doctor. Of course, I don't have that type of practice and it would be a conflict of interest if I did. My patients have had the opportunity to "try before you buy", although we'd all rather it not be under the circumstances of a needed hospitalization. Nonetheless, how do you find a good Family Physician? Or any physician for that matter?

I always encourage people to seek out a physician that friends or family are happy with or speak of highly. The best referral is one that comes from someone with personal experience. You are able to ask questions about the office staff, billing procedures, nurses, and better yet, can ask exactly what the person thinks and feels about their doctor. Don't underestimate the power of public opinion.

If the doctor you would like to see isn't accepting new patients, a personal referral from one of the doctor's existing patients is an excellent way to try to get your foot in the door. The longer the referral has been a member of the practice, the more likely you are to get an appointment. That's also a good indicator that the person referring the doctor to you is satisfied with with that particular doctor. If you do get an appointment, make sure you mention that you were able to get an appointment because "patient x spoke highly of you and referred me to you". Everyone likes to hear feedback about how they are doing.

As far as surgeons go, some of the same rules apply. Referrals from previous or existing patients is key. Satisfaction with the pre-surgical consultation, surgery, if needed, and post operative care are all things you want to know.

One of the best, but sometimes confusing, key elements of selecting a surgeon are their reluctance to operate. I would rather that my surgeon explain all of my options, including no surgery at all.

And always NEVER be afraid to ask for a second opinion. The doctor should be confident enough in his/her examination and diagnosis that he/she would feel another physician would agree with his/her assessment. If your doctor gets upset that you ask for a second opinion, get a new doctor! I also like a doctor who isn't afraid to say "I don't know", but finishes their statement with "but I'll find out". To me that means they can acknowledge their limitations AND are interested in you and learning more.

And finally, when you do find a doctor you are satisfied with, be sure to refer other patients to them. Return the favor someone else gave to you.


Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

You expect your Doctor to feel your pain. Do you feel theirs?

When most people go to see the Doctor, it's because something is wrong. And when something is wrong, you expect the person you tell to have some compassion and empathy for your discomfort and vulnerability. You expect that from your Doctor and when you don't get it, you feel put off, upset and have no problem telling everyone "what a jerk" your Doctor is. Some may resort to going to someone else.

People admitted to the hospital are much more vulnerable. At times they may be so ill that they are unable to communicate or speak for themselves. If no family is available, your Doctor acts as your advocate, making potential life or death decisions for you. In situations like these your Doctor may make those decisions by imagining "What would I do if this were a member of my own family?" Your Doctor is feeling your pain. Who feels your Doctor's pain?

Contrary to popular belief, the traditional Hippocratic oath doesn't say "First, do no harm". The original oath can be read here; http://www.pbs.org/wgbh/nova/doctors/oath_classical.html. It also dosen't say that a Doctor cares for others at the expense of himself or his family. But in fact, many of us have done just that.

When inclement weather keeps other people from traveling, or a "snow emergency" looms at dawn, illness occurs in the family or work force, some still carry out their duties. Among them are paramedics, policemen, nurses and Doctors. I, myself, have gone to work with a 104 fever from flu to take care of people MUCH less ill than I was. But, I didn't give it a second thought. In over 20 years, I've only missed one day of work. We have become civil servants, expected to be at a certain place at a given time.

How many of you would have left your family during an emergency to go down the street to take care of your neighbor? And have that neighbor express no appreciation for the fact that you chose them over your own family? Patients don't think that way.

My family has sacrificed more than I can ever repay them for. I've missed my kid's birthdays, first steps, lost teeth, school dances and plays, family vacations, not been there to take care of them when they were sick. Left my wife by herself to deal with house and home, kids, family and urgent issues. There were times I was so detached, I didn't appreciate the fact that things were still running smoothly when I did get home. I don't have to deal with things that run "smooth" so that didn't catch my attention. My oldest son wouldn't give it a second thought if I said I had to go to take care of a patient while talking to him on the phone, even if he was talking to me about a concern with one of his children; my grandchildren. "I'll have to call you back". My wife isn't my wife anymore either.

How many of you get phone calls in the middle of the night that aren't a wrong number? How many times have you been out to a movie, tried to attend a dinner party, a picnic, a day at the pool, cutting your grass, planting flowers with your kids or spouse, etc., and had to stop (and possibly leave) because you were "on call"?

Can I or my colleagues regret the attention we have given to our patients? Do I regret the countless patient encounters, the lives I have literally saved myself? How much different would the world be today if we didn't do what we do?

I think most of us would just like to hear "thank you" a little more often. And maybe, not have to take care of sooooooo many people who are abusing the system and making us all way too cynical.

So the next time you visit your Doctor's office, they answer a call after hours or weekends, or you're looking up at them as you recover from an illness in the hospital, remember who and what they left behind to take care of you.

Thank YOU for listening.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.