Healthcare Reform, Practice Management Systems, and Medical Billing

Healthcare Wolves at the Door

2012-01-29T13:12:00.000-08:00

Question:

What do you call the medical student who graduates at the bottom of his class from the worst medical school in America?

Answer:

“Doctor”

I have a relative that spends the winters in a southern resort area, better known for warm weather than the quality of the healthcare. Lacking a local physician, they went to a walk-in clinic for a routine problem, easily treated with antibiotics. Instead, they were sent for a marginally indicated CT scan at an affiliated facility. The scan was subsequently misinterpreted, leading to a further referral for invasive workup by another “contracted” provider. Luckily, after talking to me and another dozen phone calls, I managed to find them a competent local doctor who took charge, and resolved these imaginary findings with a simple ultrasound examination.

Such examples of medicine at the borderlands of over-treatment, milking the system, and outright fraud, permeate our country. This story demonstrates just how dangerous our healthcare system can be. Lurking just outside your door are many unscrupulous, inept, greedy and often well organized cadres of healthcare providers. Some are exploiting the system for personal profit, others exhibit various degrees of incompetence, both can be deadly. For the average patient, without functional knowledge of how the system works, it is easy to become a victim.

Sadly, increased government regulation, the preferred American response to most problems, has little chance of addressing these issues. Judging the competence of other physicians is extraordinarily difficult under the best of circumstances. Without the cooperation of those investigated, such reviews become almost impossible. Cases must be reviewed in detail, and legal barriers are extreme. The lines between “careful” and “over-utilization” are poorly defined at best, and any guidelines easily circumvented. It is fanciful and unrealistic to expect the government to locate and root out the evil doers.

The lesson to be learned here, is that without a foundation of goodwill, the doctor-patient relationship can become prey to the worse kind of manipulation. The first defense against the wolves at the door is a strong dose of skepticism, particularly when you don't know the physicians involved. The second requirement is finding a doctor you can trust, something which will be much harder under Obamacare.

Behind the Curtain in the State of the Union

2012-01-26T11:02:00.000-08:00

“Pay no attention to the man behind the curtain!”
― L. Frank Baum, The Wonderful Wizard of Oz

The most memorable topic in President Obama's state of the Union address was what he left out. Healthcare reform, and the state of the nations health, were relegated to one sentence of a very long speech. Obamacare, the relentless focus of the administrations' first year, has virtually fallen off the agenda. The extraordinarily contentious, poorly written, questionably funded, and legally tenuous bill, with undefined medical benefits, lack of acceptance by the states, and myriad unintended consequences was simply ignored. Now that the inevitable negative components of the bill are becoming manifest, the President is attempting to direct the eyes of the country elsewhere, concentrating on our unemployment problem.

Diverting the attention of the populace may not be so easy. Although most of the tax increases, employer penalties, and the mandate were conveniently postponed until after the election, more people are becoming aware of these less popular aspects of the legislation. The Republican nominee will make the negative impact of the bill a large part of the campaign. More importantly, the drag these new taxes will have upon employment should be made clear to the American people.

Requiring low wage employers, including farmers, discount retailers, fast-food chains, manufacturers, and small businesses to provide health insurance or pay fines will reduce hiring and result in business closings. The individual mandate will reduce disposable income and consumption for a large number of our young people. Requirements for states to increase funding of Medicaid will limit payments for education, welfare and job creation. Obamacare may well be the biggest drag upon both employment and the economy for the next several years.

As the movie so humorously demonstrated, even those living in the land of Oz can see what is in front of them. The curtain is being lifted on Obamacare, and we will soon see what is behind it, no matter what the Wizard says.

http://www.medpagetoday.com/PublicHealthPolicy/Washington-Watch/3083

When It Comes to Healthcare Reform, None of Us Are Wearing Clothes

2012-01-23T07:30:00.000-08:00

I remember when I first came to Washington. For the first six months you wonder how the hell you ever got here. For the next six months you wonder how the hell the rest of them ever got here.

Harry S. Truman

Hollywood and detective novelists have convinced America that a secret cabal of super intelligent conspirators lie behind every act of government, manipulating complex outcomes for their own gain. In such fiction, actions are directed, understanding is profound, and outcomes are intended. For better or worse, the reality is far different. An article by an industry leader, and a presentation by an “expert” give further evidence that the people in charge of healthcare reform are clueless, with narrow horizons, and minimal insight. Needless to say, these findings do not augur well for the future of healthcare reform.

The first example is an interview with the CEO of Athenahealth, a healthcare information company. Mr Bush makes extremely dubious, bizarre, and self-serving claims about how his electronic medical records will save huge amounts on medical care. To make his case, he compares American healthcare to India, two countries which could not be more different in almost every regard. He then suggests Iphones as a solution for monitoring diabetes, as if buying 50 million people with diabetes $500 dollar cellphones will somehow improve outcomes. If he was not rich and well connected politically, these statements would be considered the rantings of a crank. Instead, he gets an article in Fortune, that many people read, and some will even believe.

The second incident was a presentation by a national “expert” on his experience in Washington, a specialist with an MBA representing his medical society. He spent the first half hour telling us how little actual Congresspeople understood about healthcare reform. Most did not take the time to study the issues, instead voting along party lines or upon the instruction of pressure groups. Many were not even aware of the contents of Obamacare, much less its implications.

This expert then demonstrated his own lack of understanding by presenting a series of charts about healthcare reform, covering most of the issues I have discussed, but without analysis or insight. He blindly accepted cross-nation comparisons of expenditure and lifespan without examining the crucially important caveats about how numbers were gathered. The simple fact that not all healthcare dollars are spent to extend life was lost on him. A chart he displayed demonstrating how America spends more money with less lifespan improvement totally discounts how Orthopedics, Chiropractic, Psychiatry, Dermatology, Allergy, Plastic Surgery, and Podiatry improve life without necessarily making people live longer.

These two examples are harbingers of what is to come. As the curtain rises on Obamacare, the shortcomings of the bill will become even more apparent. Neither the Congress that passed the bill, nor the “experts” who wrote it have a deep understanding about what is in it, or what the outcomes will be. When the emperor has no clothes, we are all left naked.

http://tech.fortune.cnn.com/tag/athenahealth/

More Bad News for Obamacare, Reforms Don't Save Money After All

2012-01-20T10:03:00.000-08:00

“A politician needs the ability to foretell what is going to happen tomorrow, next week, next month, and next year. And to have the ability afterwards to explain why it didn't happen.”
Winston Churchill

Radiologists spend most of their time distinguishing between what is possible and what is true. A large number of potential diagnoses must be narrowed down to the real problem. Needless to say, the actual disease may not be the one with the best prognosis. Optimism and good intentions don't impact the results of a biopsy. Treating any disease successfully requires honesty and the willingness to make hard choices. Unfortunately, the authors and supporters of Obamacare have taken a more juvenile route. Facing the daunting and often intractable problems of American healthcare, they suggested a fanciful diagnosis, offered a relatively painless therapy, and proceeded without further testing. In a pattern familiar to all doctors, reality inevitably intervenes. Much like a patient who doesn't get better when given the wrong antibiotic, the “reforms” so confidently proffered by Obamacare are not working, and our healthcare system is going to get sicker.

A recent study by the Congressional Budget Office failed to demonstrate any cost savings from three key reforms. Disease Management, Care Coordination, and Value-Based Payment programs are major components of Obamacare, and their failure to impact medical expenses represents a crippling blow to the legislation. Without the payment reductions anticipated by these programs, the optimistic financial projections used to justify passage of the bill become even more unrealistic. The budget busting implications of the Affordable Healthcare Act will manifest much sooner than even the most pessimistic among us anticipated.

When faced with the daunting task of reforming our broken healthcare system, Congress had two choices. They could be honest, and tell the American people that hard choices needed to be made about rationing, access, and personal responsibility. Instead, they pretended that unproven technology and simple reforms would fix everything seamlessly. Like the faith healer treating tuberculosis with prayer and organic herbs, our Congress has relied upon good intentions and hope rather than reality and evidence. Sadly, our healthcare system, like a sick patient, may not recover.

http://cboblog.cbo.gov/?p=3158

What Moneyball Can Teach Us About Medicine

2012-01-16T09:36:00.000-08:00

It's unbelievable how much you don't know about the game you have been playing your whole life.
Mickey Mantle

Moneyball colorfully describes how Billy Beane used relatively simple mathematical tools to transform baseball. Using numbers, instead of “experience” and conventional wisdom, he was able to assemble a competitive baseball team for a third of the price of the New York Yankees. His bold experiment undermined the entire baseball establishment, and has been adopted by multiple other teams.

Something similar might be happening in medicine. Researchers have placed a online tool which calculates a person's expected lifespan based upon parameters such as diagnosis, age, and other medical conditions. (http://www.eprognosis.org/p/calculators.html) A patient or family can now get information their doctor may have been reluctant to tell them, or not even known. Does putting a pacemaker into grandma, who has congestive heart failure, diabetes and dementia make sense if she is going to die in 6 month? Is it worth mortgaging the house for the third round of chemotherapy with a 10% chance of working? With my risk profile, should I get mammography screening yearly or every other year, if the expected addition to lifespan is infinitesimal?

Doctors seldom make these determinations at all, and rarely present them to patients. Such a calculating, unemotional estimate of lifespan is antithetical to much of what is taught about “caring for the individual patient”. Such thinking would be anathema to large segments our healthcare community, who are more concerned with the delivery of care than it's outcome. In addition, the frequently demonstrated futility of therapy can directly conflict with the doctors' vested interests under any fee for service system.

More importantly, such a statistical approach represents a transformational and iconoclastic attitude toward the practice of medicine. The tentative attempts by reformers to treat healthcare as a cost/benefit analysis has been roundly condemned with accusations of “death panels” and the like. However, when given complete information, and faced with financial exposure, people may be less willing to endure painful and financially ruinous therapy when it is shown to be of dubious value

.
Billy Beane proved that buying players was less important than buying “wins”. It may be time to consider that with our healthcare dollar we are actually not buying medical care from doctors, hospitals and drug companies, but outcomes for our families and ourselves.

Blame it On the Other 1%

2012-01-13T10:38:00.000-08:00

"If you could kick the person in the pants responsible for most of your trouble, you wouldn't sit for a month."

Theodore Roosevelt

Everyone is familiar with the 80/20 rule, which states that 80 percent of any impact is caused by 20 percent of the people involved. Be it sales, crime, traffic accidents or healthcare costs, the majority of the impact is caused by a minority of individuals. A recent study has demonstrated an even more extreme rule in medicine. In the United States, 22% of healthcare costs are incurred by a mere 1% of the population, and 50% of the expenses are the responsibility of an equally astonishing 5% of the population.

For doctors, the study is not surprising. Alcoholics with chronic liver failure and gastrointestinal bleeding, cancer patients with multiple recurrences, diabetics with multiple organ system involvement, back pain sufferers with repeated surgeries, and stroke victims needing long term care are among the problems that fill many hospital practices. These people require multiple procedures, imaging studies, intensive nursing, and innumerable medications that can easily cost hundreds of thousands, if not millions of dollars.

Upon consideration the numbers are staggering, and undermine many of the arguments flying around about healthcare reform. Stopping Obama's “unnecessary” tonsillectomies, computerizing medical records, limiting mammography screening, or capping pharmacy company profits will do little to impact the spending on these very sick people. Once in the system, it becomes virtually impossible to stop treatment or limit expenditures. Denying additional, potentially curative therapy because of cost is not an option in America at this time, no matter how much has been previously spent.

This issue underscores the hypocrisy and cowardice that underscores the entire discussion about Obamacare and reform. There can be no solution to our healthcare problems without controlling costs. The sad reality is that 5% of the people in our country are using 50% of the healthcare, and no reform program has any chance of working until this inconvenient truth is addressed. However, the hard choices, such as rationing, policy limits, patient responsibility, or cost effectiveness of therapies have never been debated, or even discussed, by those who passed Obamacare. Congress kicked the can down the road, knocked the doctors to the curb, hit small business in the groin, but missed the ball altogether.

http://www.usatoday.com/news/washington/story/2012-01-11/health-care-costs-11/52505562/1

Would you pay for your services?

2012-01-10T01:30:00.000-08:00

Harvey Schmiedeke, President of Survival Strategies and author of Keys to Private Practice Success, used to have a client in a northern US border area (p. 134). "Canada as you know has socialized healthcare, supposedly offering everything for free. The large majority of his client's patients were Canadians. They would go through the hassle of clearing customs and drive hours to pay him $78 US cash for treatment they supposedly could get for free in their own country. Why? Because he had the reputation of handling headaches and they knew if they went to him they'd be seen immediately and they'd get better!"

In every industry, regardless of geography, referrals, word of mouth are the strongest and most valuable source of customers and patients.

What services could you offer to:

differentiate and elevate your practice above the competition?
attract highly motivated and loyal patients?
cause patients to rave about your services to their friends and families?
add significant revenue to your practice?

For instance, can you offer any one or a combination of these products:

Equipment, supplies, or supplements
Massage
Wellness and Fitness Program
Sports Enhancements Program
Injury Prevention and Ergonomic Re-Design
Vestibular Balance Program
Obesity Control Program

What are the steps to discover or invent a program that would really work in your area?

Some coaches and practice management consultants, suggest surveys are effective means of discovery but do they really work?

I doubt Harvey's client surveyed his Canadian neighbors prior to offering his headache handling services. Ford's notorious quote is: "If I asked my clients what they want, they would ask for a faster horse." Steve Jobs too is famous for NOT doing any surveys and trusting his intuition.

Apple Computer president Michael Scott in 1980 wrote a memo announcing that "EFFECTIVE IMMEDIATELY!! NO MORE TYPEWRITERS ARE TO BE PURCHASED, LEASED, etc., etc." by the computer company, with a goal to eliminate typewriters by 1 January 1981.

In 1988, Microsoft manager Paul Maritz sent Brian Valentine, test manager for Microsoft LAN Manager, an email titled "Eating our own Dogfood", challenging him to increase internal usage of the company's product. The idea behind "dogfooding" is that if you expect customers to buy your products, you should also be willing to use them. Some people call this "do what you preach".

Dogfooding needs to be transparent and honest: "watered-down examples, such as auto dealers' policy of making salespeople drive the brands they sell, or Coca-Cola allowing no Pepsi products in corporate offices ... are irrelevant." (Wikipedia) A perceived advantage beyond marketing is that it should allow employees to test the products in real, complex scenarios, and it gives management pre-launch a sense of progress as the product is being used in practice.

"Microsoft's use of Windows and .NET would be irrelevant except for one thing: Its software project leads and on-line services managers do have the freedom to choose."

If you think about it, patients, like customers, seldom know what they really need or want. Surveys only help to those who sell survey management services to you.

When it comes to your practice, you and your staff need to be the final judge of your service. Steve Jobs wanted a computer that he would want to use instead of the typewriter. Ford wanted a car that he would want to drive instead of a horse. I want a software service that my staff and I would WANT to use to manage our company. I want a blog that I choose to read it, that would teach me something new.

Think about it - if you cannot use it, why would anybody else want to use it? If you offered an obesity management program while you weighed 250 pounds, do you think you would attract any patients?

On the other hand, if your program was that good that you used it yourself, how easy would it be to tell your story and get paid for your services? Would it really matter if insurance covered it?

Trust your intuition and you will have rave patients who tell their friends about your services!

The Real Impact of Obamacare, Time to Learn Swedish?

2012-01-08T10:21:00.000-08:00

From this day on, the official language of San Marcos will be Swedish. Silence! In addition to that, all citizens will be required to change their underwear every half-hour. Underwear will be worn on the outside so we can check.

Esposito, new revolutionary leader of the country of San Marcos

From the movie “Banana's”

Woody Allen's spoof on government reform is one of my favorites. However, like all satire, it has a core of truth. Top down attempts to change human behavior, no matter how well intentioned, often result in edicts and rules that are ineffective, counterproductive, stupid or silly. For many Americans the primary impact of Obamacare will be one of the innumerable unintended consequences of this poorly designed legislation. The seemingly reasonable reforms, originating at national levels, will be transformed into unrecognizable decrees as they are implemented by multitudes of bureaucracies and poorly trained clerics. Anyone who has visited the DMV, post office, or airline counters understands just how poorly this model works. A recent experience of a doctor friend of mine demonstrates how this nightmare is coming to healthcare near you.

Many people think Radiologists fix radios, or take X-rays, medically oriented TV shows routinely minimize their role. In fact, modern Radiologists, train for 6 years after medical school, make the diagnosis for most diseases, see patients, perform surgical procedures, treat cancers, and prescribe many medications. Nevertheless, the pharmacists at a local drug store recently decided that a Radiologist friend of mine was not qualified to prescribe a medication because it was “outside of his field of practice”. He was told that Radiologists, like nurse practitioners, were not familiar enough with a particular medication(not a narcotic by the way), and his prescriptions would not be honored. It did not matter that this particular friend had practiced internal medicine prior to being a Radiologist, had a medical license, had been using this particular drug for many years, and knows more about the organ system involved than most specialists. A rule was a rule, and the clerk, with one year of pharmacy training, was going to follow it.

Of course, one can appreciate what actually happened. In order to address the real problem of improper and over-prescription of drugs, for which they are partially responsible, pharmacies resort to policies and procedures attempting to limit abuses. Lacking any understanding or insight about what Radiology is, and with Radiologists being low volume referrers, it is easy to group my colleagues with nurse practitioners and physician assistants. The rules satisfy prying government investigators, and give the appearance that pharmacies care about improper prescribing, despite the fact that they make huge profits from it. Such “bureaucracy think” is the typical response of those without the insight or intelligence to understand a situation, or the power or will to address it.

This isn't the first, nor will it be the last petty, nonsensical and comical imposition that healthcare reform will make upon all of us. I for one, am seriously considering learning Swedish, and buying new underwear.

Obamacare Watch, How Do You Tell When a Program is Failing?

2012-01-05T12:05:00.001-08:00

“Failure is not a single, cataclysmic event. You don't fail overnight. Instead, failure is a few errors in judgement, repeated every day.”

Jim Rohn

I spent three years on the executive committee of my hospital. Although these doctors were nominally in charge of improving medical care, the reality was a bit different. A quality assurance nurse, would dream up some half-baked plan to address a perceived problem, and the hospital administration would then approve it over the ignored objections of the doctors.(pretty similar to Obamacare). Needless to say, many of these “initiatives” did not work out as planned. For instance, in an attempt to cut transport times, more personnel were assigned to pushing patient gurneys. However, without more nurses or clerical help, the units were unable to assign rooms quickly enough, and patients instead waited on the floors. Changing the speed of movement impacted the nursing units, the laboratory, radiology, patient records, and even the required number of elevators. The decreed wait times were first extended, and then dropped altogether.

Obamacare is experiencing a similar pattern. The naïve, poorly conceived and utopian goals of the legislation are breaking apart on the hard rocks of reality. Fixing complex systems requires an appreciation of the myriad interconnections between multiple components, issues ignored by the lobbyists who wrote the affordable healthcare act. Deadlines after deadline is being extended, ignored, or simply discarded. The list is growing rapidly, long term care insurance, 80% expenditure limits, Medicaid coverage mandates, national insurance coverage guidelines, 1400 assorted waivers, and now electronic medical record adoption timetables are being acknowledged as unworkable. Just like our hospital, the bureaucrats in charge of implementing programs are learning that actions have consequences.

Successfully addressing highly complex issues requires deep understanding, long term planning, buy-in of the impacted parties, effective response to feedback and solid leadership, all conspicuously lacking from this legislation. The failure of Obamacare will not be broadcast noisily in the papers like an election or celebrity divorce. Instead it will be a slow, relentless and excruciatingly painful series of small failures, accumulating at an ever faster rate, until even the most zealous supporter finally relents. Not something to look forward to.

http://www.ama-assn.org/amednews/2011/12/12/gvl11212.htm

Two-Tiered Medicine, As Inevitable as Inequality

2012-01-02T13:42:00.001-08:00

“The worst form of inequality is to try to make unequal things equal.”

Aristotle

One lesson of age is learning that life is inherently unfair. Denying this fact is a central delusion of youth, and a major hypocrisy of government. Many healthcare reformers, no matter how well credentialed, are more concerned with maintaining this fiction than actually fixing things.

The primary motivation behind many proposals, particularly single payer, is equality of care for all. Would-be reformers find the inequality of care so repugnant that they are are willing to undermine the entire healthcare system to avoid such realities. Government programs in Canada and England make private care difficult to obtain for just this reason. Additionally, a parallel private system erodes support for needed taxes, emphasizes disparities, and makes the bureaucratic inefficiencies of the government system more apparent.

Nevertheless, those with the means will always find a way to obtain better care. Those able to pay for more personal care, the latest drug, a private room, or a better surgeon will always find someone to provide that service. Unless such premium medicine is prohibited by law, our capitalist system guarantees such demand will be met. The rapid proliferation of such “concierge” or “retainer” medicine attests to this inevitability. In my city, virtually every successful internist has adopted this type of practice. For a fee, averaging about $2500 a year, the doctor guarantees to give a higher level of care, answer your phone calls, and give you more than 15 minutes per appointment. They also bill your insurance, and help with your paperwork. Doctors can ensure their income and escape the limitations on fees, visit times, and care restrictions imposed by insurance companies and Medicare.

In the future, if Obamacare is implemented, I expect this trend to expand beyond primary care. Specialists, outpatient surgery centers, and hospitals, offering premium services will operate outside of the Medicare/Obamacare umbrella. Freed from the red tape, regulations, and fee structure the government imposes, these providers will offer care for patients at whatever level one is willing to pay for. Additionally, without the bureaucracy, reporting requirements, need to cover the chronically ill, or obligation to subsidize non-paying patients, such a system could give better care, more cheaply, than the parallel government program.

Such a two tier system, may well be the natural market reaction to Obamacare and Medicare reform. The government cannot legislate equality of care, now or in the time of Aristotle. It has been over 2500 years since his statement, and the proponents of Obamacare haven't learned a thing.

My Predictions for 2012

2011-12-30T10:08:00.000-08:00

“The groundhog is like most other prophets; it delivers its prediction and then disappears.”

Bill Vaughn

My mother once told me that any fool can make predictions, which indubitably qualifies me to pontificate about what will happen next year in healthcare. So in sometimes honored tradition of making such predictions, and understanding that no one is ever held accountable, here are mine for 2012.

Mitt Romney gets the Republican nomination, and expresses his strong opposition to Obamacare. Ironically, the affordable healthcare act was based upon the legislation Romney championed while governor of Massachusetts,
Obamacare, and healthcare reform, become a central part of the Presidential debate. The unworkability of many of the provisions, as well as the fantastical projections behind the bill, become major talking points of the candidates. The administration suggests the problems can be fixed, while the Republicans insist the bill must be repealed.
The Supreme Court rules in favor of the legislation in June or July, keeping the issue before the populace just Obama is trying to deflect attention away from the bill, which is now opposed by most Americans.
More states pile on, cutting Medicaid severely, refusing to implement the Obamacare mandates, and pursuing various legal strategies in state courts.
Congress, locked in tight races, harden their stances and refuse to compromise. Continued gridlock keeps them from addressing the doc fix, Medicare reform, national coverage standards, or drug prices.
Romney wins a close election. The Republicans keep the House, but the Democrats keep the Senate.
Romney declares Obamacare DOA, between waivers, refusal to fund the bureaucracy, and lack of state action, the bill is not implemented, despite never being formally repealed. Democrats universally adopt the “single payer” approach, and make it their new party platform. Romney calls for “real” reform, but is opposed by the right wing of his own party, and no progress is made.
Healthcare costs moderate, as utilization rates decrease with increased co-pays and more uninsured. Present trends of decreased access, increased out of pocket costs, and decreasing reimbursement, continue.
The cynical among us realize that after four years of debate and billions of dollars spent, nothing has changed.

Holistic Medicine is Great, Until You Get Sick

2011-12-27T16:00:00.000-08:00

“Either he's dead or my watch has stopped.”

Groucho Marx

One universal belief underlying healthcare reform is an emphasis on considering the patient as a whole, attempting to include all aspects of the patient, mind, body and spirit. Healthcare plans, insurance companies, hospitals and reformers are falling over themselves emphasizing their holistic approaches. It is therefore deeply ironic that some of the most important advances in medicine, particularly cardiology, have come from a diametrically opposed position. Millions of lives have been saved, and many more millions have had their life improved, because doctors have viewed the heart as a simple pump. The mechanistic perception of the heart as a machine, with fuel(blood), flow controls(valves), power(muscle), and timing system(electrical impulses), has resulted in therapies which have converted scourge of heart disease from a silent killer into a manageable problem.

Viewing the coronary arteries as a fuel delivery system, with repairable blockages, has resulted in curative surgery and stent deployments, which forestall even severe coronary artery disease. Heart valves can be replaced or repaired, even in the youngest or oldest patients. Rapid interventions to preserve or even repair heart muscle are now routine. A deep appreciation of the complexities of heart electro-physiology, and the ability to correct problems with drugs or pacemakers, has improved the lives of millions.

These incredible advances in heart disease have been made specifically because this organ system could be isolated from the person as a whole. If doctors could not separate the cardiovascular system from the rest of the body, these breakthroughs would never have happened. One of the primary forces driving the sub-specialization of medicine, so decried by reformers, is the success achieved by these methods. Unfortunately, the politicians, economists, reformers, and most Americans, simply don't get it. Strong financial forces, and many lobbying groups, have overwhelming incentives to promote primary care, with vague and unproven promises of prevention and efficiencies. Holistic medicine makes for good soundbites, but when your left main coronary artery is blocked, or your heart is not beating on time, you need a highly trained specialist. What the politicians and reformers haven't told you is that despite their promises, these lifesavers are going to be much harder to find after Obamacare.

A Holiday Gift For You, How to Make Some Money From Obamacare

2011-12-24T11:22:00.000-08:00

You'll always miss 100% of the shots you don't take. ~Wayne Gretzky

Doctors are scared spineless, and their paranoia is justified. Congress is on the verge of cutting Medicare access of millions based upon moronic ideology and unbridled egos. Simultaneously, in an ultimate act of cynical cowardice,the administration dumped the implementation of Obamacare to the epically unprepared and incompetent state governments. Never has the fate of such a large portion of the American economy, and so many sick, been put in the hands of a more clueless, corrupt and ignorant group of bureaucrats. Medical providers are faced with a unprecedented degree of uncertainty, both for their patients, and their financial futures.

Doctors are by nature risk averse. Many choose medicine for it's security and virtual guarantee of lucrative employment. Years of medical training demonstrate the downside of rash actions. No one operates first, and asks questions later. When faced with fear and uncertainty, most doctors step back and consider the situation. These personality traits carry over into economic behavior. In the spirit of making lemonade when given lemons, the savvy among us can use this fear to make some intelligent investments.

With the future so uncertain, doctors will cut back dramatically on medical equipment purchases, and plans to expand. Insurance companies do not increase payments for better CT scanners or faster MRI machines. Adding another operating room, or new partner only makes sense if one anticipates more patients. Attracting new business with an improved procedure doesn't work if Medicare won't pay. If your nurse is not busy, perhaps the receptionist can be let go. Physicians will be resistant to any change, such as signing new contracts, spending more money, or taking any risk.

The savvy investor can use this insight to sell short medical equipment makers. The largest ones are diversified, but smaller companies, particularly the mammography and ultrasound companies, will be hit hard. Medical REIT's will face new doctors reluctance to signing leases. Companies dependent on rapid growth, such as those in the medical IT space, will face slower markets, and lower PE ratios.

Companies that remove risk exposure may prosper. Management companies that employ ER doctors, hospitalists, and general practitioners should thrive. Hospitals and industries that can employ physicians directly should do well. Those providers lucky enough to function outside of the Medicare/Insurance/Hospital umbrella, such as concierge practices, should be the new growth area of medicine. Every great upheaval opens new opportunities.

Wishing everyone the best for the holidays and the New Year.

The Doc Fix Stalemate Threatens Healthcare Once Again

2011-12-21T09:52:00.000-08:00

" It's deja vu all over again"

Yogi Berra

My very first post in June of 2010 dealt with the “doc fix”, the yearly Congressional vote to reverse an automatic 27% reduction in Medicare fees to physicians. Ironically, 18 months later, following a monumental reform of our healthcare system, our selfless leaders, have deferred voting on the “doc fix” once again. Unless something is passed in the next few weeks, the hapless bureaucrats in charge of Medicare with no choice but to cut payments.

The negative impact of these cuts is not contested. Both parties agree such a precipitous decrease in fees will reduce access to care. Many physicians have already stopped seeing Medicare patients, and these lower payments will dramatically accelerate this process. When fees received do not cover overhead or malpractice costs, many doctors will be unable to stay in business. This is not an idle threat, substantial numbers of older physicians may find it cheaper to simply retire than to continue operating at a loss. The traditional solution of cost shifting, raising fees on patients with traditional insurance, is no longer possible, particularly after Obamacare. Perhaps most importantly, and what those playing politics here do not understand, is that once a doctor leaves practice, it takes many years and great expense, to replace them.

This Congressional imbroglio represents a microcosm for both healthcare reform and our entire political process On the one hand, the benefits of increasing access to healthcare are appreciated by all, no one, particularly politicians, wishes to deny medical care to the elderly. However, no one knows where the money will come from. Payments need to come from taxes, borrowing, or cuts in other programs, all with conflicting moral imperatives, constituents, and lobbyists. The rational allocation of resources based upon a open dialogue between the many opposing demands of our society seems out of reach. Our politicians adamantly refuse to honestly confront the issues, choosing to appeal to our fears instead of our reason.

Until we can break this pattern of inserting short term fixes to long term problems, we will be forced to confront these same issues repeatedly. Unfortunately, failing to pass the doc fix just once will make fixing humpty dumpty look like a easy problem.

Obama Leaves the Hard Decisions to the States, A Recipe for Failure

2011-12-18T09:45:00.000-08:00

Only when the tide goes out do you discover who's been swimming naked
Warren Buffet

“Never ascribe to malice that which can adequately be explained by incompetence”

Napoleon Bonaparte

Virtually every doctor has seen an incompetent colleague botch a surgery, resuscitation or other procedure. These disasters are often similar. Whether due to lack of skill, experience or knowledge, some small error is compounded by multiple futile attempts to correct the first mistake. As things go from bad to worse, the physician in charge gets more flustered, often leading to death of the patient.

Sometimes the guilty doctor turns around and attempts to blame the nurses or assistants in some childlike attempt to deflect the guilt, recriminations, and lawsuits.
The Obama administrations decision to allow the states to specify healthcare benefits is a similar monumental failure. This inglorious evasion demonstrates both the impracticality of the bill, and the continued refusal of supporters to face the harsh realities so blatantly disregarded during the Congressional debate. This decision represents an abnegation of responsibility, and the beginning of a downward spiral which guarantees the goals of Obamcare will not be achieved.

The political imperative to pass “something” was so overwhelming that Congress approved the bill without making basic decisions about who would be covered, what procedures would be included, and who would pay for what. Such crucial choices were felt to be too contentious by the fearless leaders who passed the bill, and were left to ineffable “committees” to decide. The dirty secret of Obamacare, which supporters still hope to conceal, is that there is simply not enough money to cover even the most basic healthcare costs. Politicians made bold promises of coverage for all, but conveniently ignored the fiscal realities. Even with the mandate, any national insurance will barely cover the most basic medical problems. The stipulation of full and free coverage for all, leveraged to force passage of the bill, is at best a cynical distortion, and at worst a boldface lie.

When faced with the impossible gap between promise and reality, the Congress and their bureaucrats did what they do best, they passed the buck. Lacking the skill, knowledge, and experience to make the politically contentious, medically difficult, and financially impossible choices required, they dumped them onto the even less competent States. The State governments, with neither the money, nor infrastructure, are charged with implementing these impossibly complex healthcare systems.

Needless to say, this is a recipe for failure. Many States, already bankrupt and careening toward fiscal disaster, can no more design and administer Obamacare than a first year medical student could perform a complicated neurosurgery. When these disasters occur, I can envision the supporters of Obamacare turning around and blaming the States, sort of like that incompetent surgeon who blames the nurse. Unfortunately, the patient still dies.

http://www.nytimes.com/2011/12/17/health/policy/health-care-law-to-allow-states-to-pick-benefits.html?_r=1&ref=health

Another Misleading Headline about Obamacare

2011-12-15T13:44:00.000-08:00

Advertisements contain the only truths to be relied on in a newspaper.

Mark Twain

One negative consequence of the proliferation of alternative news sources is that traditional media has lost any pretense of objectivity. A particularly egregious transgressor is the Los Angeles Times, which has forgotten the distinction between news and editorials. In order to continue their ideologically based support of Obamacare, a recent article has contorted reality to a degree that would make the Cirque Du Soliel proud. The piece in question entitled “Obama administration wins plaudits from healthcare law critics”, should have been called “Administration bows to Lobbyist Pressure” or “Even Obama admits healthcare plan will not work”. If you can't change the facts, manipulate the headlines.

The body of the article describe how the administration is granting waivers for various requirements of Obamacare. The government will allow insurance companies to limit benefits, permit companies to offer substandard policies, grant waivers to insurance companies and unions for the 80% payout rule, and free states from Medicaid requirements. I have written about each of these issues previously, but the need for these waivers demonstrate several of the major shortcoming of Obamacare. The legislation never specified what benefits would be covered at which price, in part because an honest accounting would point out the bogus assumptions of cost and utilization that went into the bill. Additionally, the 80% benefit payout ratio can only be met by the very largest of insurance companies insuring healthy populations. Smaller companies, or those insuring the poor or chronically ill cannot possibly meet this arbitrary requirement. Finally, federally mandated rules forcing the states to fund 30 million new Medicaid recipients will bankrupt the states, forcing the firing of hundreds of thousands of workers.

Of course, understanding these difficulties requires the LA Times writers to actually read the bill, do the math, and question their political agenda, which is too much to ask. Unfortunately, the misinformation transmitted by this, and other articles, is not benign. Many, if not most, people obtain what limited knowledge they have about Obamacare from such sources. Unless the truth is told, the unworkability of the legislation will remain hidden until , bankrupt states, failed hospitals, fired teachers, and inability to find a doctor make the reality all to clear. It is time to read the advertisements, or my blog.

http://www.latimes.com/health/la-na-health-law-implement-20111215,0,6033978.story

Where Are The Obamacare Protesters?

2011-12-12T11:42:00.000-08:00

For most of us, the first impact of Obamacare will be the closure of our local retail mall and increased food prices.

D. Cassel

I performed thousands of biopsies during my career as an Interventional Radiologist, and told many people they had cancer. Human beings react to such immanent threats in a variety of ways including denial, fatalistic acceptance, or a stoic determination to fight. Nevertheless, once people learned about their disease, and the potential treatments, most ended up making rational choices about their therapy.

I am therefore somewhat surprised by the lack of reaction to the pending specter of Obamacare, particularly upon younger workers and the targeted industries, which include the farming, service and retail. These individuals and companies will be on the hook for $4000 per person in additional healthcare costs as of January 2014. For many workers, this is the equivalent of 6 months rent, yearly overtime, or car expenses. For many industries, $4000 per worker is their total profit margin.

To our esteemed Congressional leaders, these amounts are no more than a rounding error, as they can print money, set their own salaries, or go to work lobbying for a drug company. However for many young graduates trying to pay off college loans, or farmers trying to pick their crop, this new “tax by another name” could mean bankruptcy or foreclosure. With so many workers and industries suffering at the margin, the impact of Obamacare could be devastating, both on individuals and our economy.

Remarkably, little is being said, either by our leaders, or the ill-fated victims in the healthcare reform wars. Where are the activists demonstrating against this regressive charge aimed at the young, or the farm workers marching against the loss of their industry? Those 22 year old's protesting on Wall Street will soon be paying the individual mandate to subsidize care for “fat cat” bankers and others who already have insurance. For most of us, the first impact of Obamacare will be the closure of our local retail mall and increased food prices.

I guess many are hoping for substantial changes, or even repeal, of the bill prior to implementation. I chalk this up to wishful thinking and denial, sort of like Wiley Coyote on his way down.

Another Misunderstanding at the Heart of Healthcare Reform

2011-12-09T11:45:00.000-08:00

Truth is mighty and will prevail. There is nothing wrong with this, except that it ain't so.
Mark Twain

One can characterize most of the advances of modern medicine as the transformation of acute diseases into chronic conditions. Illnesses which used to kill within weeks or months can now be treated, enabling people to live for many years. Heart, kidney, and vascular disease, diabetes, Alzheimer's and cancer have all become long term problems, often requiring many years of intense and expensive therapy. In fact, most doctors spend the majority of their time monitoring people with these illnesses. Endless office visits, effort, and money, are spent adjusting medications, monitoring glucose levels, scanning for cancer recurrence, and looking for re-stenosis of vessels. “Cure” is never contemplated, but people can live many years, happily or not.

Sadly, the economists, politicians, journalists, and other “reformers” who passed Obamacare, and pontificate on our healthcare system, do not understand this transition. Most still think of medicine based upon their own experiences, augmented by the TV shows, which so misrepresent what doctors actually do. Most lay people consider illness as something a doctor can cure(or not) quickly, with some drug, surgery, or natural foods. TV shows do not depict Dr. House seeing 40 patients a day, managing various combinations of diabetes, high blood pressure, emphysema and arthritis pain. Often, the only crucial decision doctors make is divining which of 10 medications some forgetful patient actually took. Sometimes the most difficult issue is finding some way to get an elderly patient to their next appointment now that their wife can no longer drive. Hours are spent trying to convince an insurance company to pay for a more expensive drug which only needs to be taken once a day. The goal of healthcare is frequently not to cure anyone, but keeping a sick person out of the hospital or nursing home for another few months.

This fundamental disconnect lies at the heart of our healthcare debate. “Prevention”, electronic medical records, reducing the number of tonsillectomies, and other political nostrums, will have no impact upon the expense of caring for the chronically ill. Obamacare does not address these problems because the people who passed the bill do not understand what medicine is, or what doctors actually do. Nothing in the legislation reduces the expense of taking care of these patients, or acknowledges the impact of chronic diseases on medical costs. The impossible choices requiring rationing of limited resources were not made, as they were too politically difficult, but the actual facts cannot be bloviated away. The truth may not prevail, but it will make itself known.

The Downside of Obamacare's Dream. The Dangers of Sharing Medical Information

2011-12-06T11:32:00.000-08:00

“They have computers, and they may have other weapons of mass destruction."

Janet Reno

Innumerable science fiction authors have warned us about a terrorist releasing a genetically engineered virus that kills thousands. However, these pundits have not yet envisioned an equally lethal, more simply designed threat. Computer viruses represent a real menace to CT and MRI scanners, patient monitoring equipment, radiation therapy machines,, hospital management systems, medical records, and the entire Medicare bureaucracy. The problem is not trivial. How many people would die if CT scans became unavailable, respirators failed, or Medicare was shut down? Thousands would die, and the costs of re-engineering our entire medical establishment would be astronomical.

The Stuxnet virus, used against the Iranian nuclear program, demonstrates the power of a computer virus designed to destroy the inner workings of industrial equipment. The software which runs our medical infrastructure, operations, equipment, and payments, is woefully unequipped to handle attacks by sophisticated terrorists or other enemies who wish to hurt our country. Whatever security these systems have was designed to insure privacy, not to prevent military level attacks. No programmer, in their wildest dreams, could have conceived, much less guard against, such malicious intent.

Furthermore, in the past, such equipment and systems were essentially isolated. Scanners, medical record systems, and billing systems were originally built as stand alone entities. An enemy could only damage one machine at a time. However, as information systems, imaging departments, and insurance companies become networked, the malicious hacker can gain access to thousands of systems simultaneously. The third rate hodgepodge of network administrators and security personel guarding or infrastructure is completely unprepared for any organized attack.

Although merely speculation at the present time, the potential for such a catastrophe must be appreciated. The cavalier manner that we are opening up our medical infrastructure to attack may have grim consequences. Obamacare's dream of sharing information has a real nightmare downside.

Obamacare's Biggest Problem? The Secrets

2011-12-02T11:09:00.000-08:00

"The liberties of a people never were, nor ever will be, secure, when the transactions of their rulers may be concealed from them. . . . To cover with the veil of secrecy the common routine of business, is an abomination in the eyes of every intelligent man."

Patrick Henry

"As long as the government's actions are secret, it cannot be held accountable. A government for the people and by the people should be transparent to the people."

Al Gore

If you actually read the Obamacare legislation, the biggest surprise is not what the bill contains, but what it leaves out. Nowhere do the authors indicate what healthcare will be covered, or how much insurance entities will pay for these services. In fact, the structure of insurance exchanges, what the individual mandate will buy, and who will be covered by Medicaid, are conspicuously left out. The really difficult decisions, about limits to care, payment caps, and end of life decisions were never debated by Congress, or confronted in the bill.

Two major issues needed to be addressed by Congress. First, the American people needed to be told the truth about the irreconcilable demands for unlimited care and our inability to pay for it. Secondly our leaders needed to make the hard decisions about who would pay, how much, to whom, and for what. Of course, such Solomon-like adjudication would require courage, intelligence, insight, and fortitude, not exactly the strong points of our leadership. So the President and Congress choose a method more suited to their leadership style, they set up a committee.

Somewhere in the innumerable office buildings of Washington, appointed, lower level bureaucrats, are meeting in secret. These anonymous paper pushers, without accountability, responsibility, medical experience, or understanding, are determining the future of American healthcare. Sometime before 2014, the incomparably lengthy and impenetrable reports of these modern day Star Chambers will be made public, and lawyers will spend months figuring out what they actually decided. The favored lobbyists that were granted access to these committees will be revealed by the winners and losers in the money wars. Friends and benefactors of the administration and powerful Congresspeople will make sure their financial interests are benefited, at the expense of everyone else.

Government policy being made by such secret committee underlies much of the resentment that has spawned the Tea Party and Occupy Wall Street movements. As strong as those emotions are, it is vital to realize that tax policy affect your money, but Obamacare will impact our lives. This lack of transparency may well be the greatest failure of this manifestly flawed healthcare legislation. The time to get angry is now.

Electronic Medical Records, a Target for Thieves

2011-11-29T10:03:00.000-08:00

Why do you rob banks?

“Because that's where the money is”

Willie Sutton

Thieves used to love X-ray film, as it contains large amounts of silver. One of the great advantages of computerized radiology is that no one is interested in stealing the images anymore, as they don’t contain anything that is easily converted to cash. Unfortunately, the same cannot be said for electronic medical records. Besides the obvious privacy issues, the demographic data contained in these records has substantial, if unappreciated, financial value. I predict that theft of electronic medical records will become a major problem in the next several years, and may become the greatest single issue blocking their utility.

Imagine the amount of money a company marketing medical supplies could save if they had names and addresses of those with diabetes or back pain. Health insurance companies and employers could screen for undisclosed medical problems, or offer competitive deals to the healthy. Attorneys, competing doctors, and home healthcare services could troll for cases. Life insurance salesman could target their sales, and nursing homes could market for specific illness. Patient groups with similar problems could amalgamate and bargain for cheaper care . On the more nefarious side, information could be used for blackmail, choosing houses to rob, or for fraud. The possibilities are endless, and will motivate clever thieves for years.

The only barrier to such potentially lucrative opportunities are whatever security is built into EMR systems, along with and the people using those systems. By any criteria, the medical community is poorly prepared on both counts. Many EMR systems have been cobbled together by tech savvy doctors or programmers who have no real background in mission critical design. Computer security has never been taught in medical school, and is of low priority for those seeking to build the lowest cost products. The rudimentary security on most EMR systems would be laughable to the sophisticated cyber-thieves who have been hacking military and government records for years . More importantly, the clerks, nurses, doctors and administrators actually using EMR are mostly clueless, without training, understanding, or the foggiest idea of the issues involved. Needless to say, a recently hired hospital clerk would be powerless against a dedicated attack, or the most simple ruse.

It is only a matter of time before EMR systems are subjected to organized, well planned and relentless assault from those seeking to exploit a vulnerable source of valuable information. The damage done to the patients, hospitals, and practitioners involved will be immense, and could end practices, and close hospitals. Adding the needed security will be time consuming, very costly, and further compromise the questionable gains obtained from EMR systems. It is vital to ask whether your EMR was designed by someone who understands security, is housed in a secure site, and is updated frequently. They are coming for your medical records, better get ready.

How Many Teachers Need to Be Fired to Fund Obamacare? We Are About to Find Out

2011-11-27T08:00:00.000-08:00

Each betrayal begins with trust
anonymous

A true friend stabs you in the front
Oscar Wilde

It is sadly ironic that teachers, police, fireman, and other public workers are the people Obamacare hurts first, and most severely. These individuals and their unions have been among the most stalwart supporters of the legislation, both before and after passage. They have been successfully fooled by the deceptive manner in which the “affordable healthcare” bill was passed and funded, and remain unaware that they are directly targeted by the legislation.

No one questions the goal of universal medical insurance. The problem with Obamacare was always how to pay for it. Very early in the discussions, analysts realized that large, politically unacceptable, tax increases would be needed to fund the program. Congressional leaders, rather than address this issue honestly, chose chicanery. First, they instituted a regressive tax on young people, calling it an individual mandate. Secondly, our leaders shifted a huge percentage of the costs onto the states, with no provision for funding.

The legislation demands that states enroll millions of new people in Medicaid, without any increased funding from the federal government. If the Supreme Court upholds the power of the Congress to enforce these mandates, the states will have no recourse. Most states are already bankrupt, and cannot deficit spend or print money. Raising taxes is frequently impossible, and represents political suicide. In order to balance their budgets, states must cut services. The only choice left is firing teachers, police and fire people, closing prisons and reducing other programs. How many need to be fired? The number of new people eligible for Medicaid is about 30 million. One could expect medicaid expenditures of at least $3500 per person. This is at least $100 billion dollars, needed in 2014. With salary, benefits, and overhead, this is the equivalent of a MILLION teachers.

These numbers are staggering, but the math is pretty clear. Amazingly, these public employees, and their representatives, seem completely oblivious to the coming storm. Teachers and state workers should be the groups leading opposition to the bill, but polls suggest their support is unwavering. Our teachers, and other public workers have been betrayed by Congress, but don't appear to know it yet. Teachers should be reading the fine print of Obamacare, doing the 'rthmatic, and writing their Congresspeople, the semester is almost over.

Changing Expectations and the Failures of Our Government and Healthcare System

2011-11-25T13:45:00.001-08:00

Sometimes I wonder whether the world is being run by smart people who are putting us on or by imbeciles who really mean it.

Mark Twain

The Congress and doctors in the United States have an eerily similar relationship with the American people. The Congress as a whole gets an embarrassingly low 9% approval rating, yet voters re-elect their same representatives year after year. Likewise, Americans rank the national healthcare system poorly, but like and want to keep their personal doctor. These contradictory statements demonstrate how expectations have changed for government and medical care in the minds of Americans. Our inability to understand and address this fundamental shift lies at the heart of healthcare reform.

A close reading of the Constitution, and the Federalist papers clearly point out that our founding fathers viewed government as a necessary evil. The national government had required powers, but was also viewed as a danger from which the citizens needed protection. The division of government power was designed to limit the influence of one branch, and prevent change. It was never the federal government’s purpose to ensure jobs, retirement, defense contracts, food-stamps, liver transplants, equality, Viagra, or high self-esteem.

Somewhere along the way, this all changed. The government is now seen as a mechanism to secure the individual desires of the voters, be they financial, religious, social, medical or moral. When one considers the diverse nature of our population it is no wonder that everyone cannot get everything they want. Groups with similar goals wield their influence to obtain bigger slices of the pie from Congress, at the expense of everyone else. Obamacare was a perfect example of how Unions, big business and drug companies rammed through a law for their benefit at the expense of the young, small business, and medical specialists. Our system of government was not designed to allocate the spoils of government, and is not very good at it.

Our healthcare system had undergone a similar transition. Sixty years ago most cancers were fatal, heart disease was mostly untreatable, and people still died from gastric ulcers. Expectations for healthcare were low, and doctors frequently had little to offer in the face of disease. Today many view health, long life, and happiness as a “right”, owed to them by the medical community. Doctors are expected to cheerfully and speedily cure their problems caused by years of overeating, alcohol or tobacco without cost or complication. Pain, be it physical or mental, is no longer accepted as being a part of the human condition. Age, prior bad acts, lack of compliance, or ability to pay are no longer viewed as impediments to the most intensive and expensive care. With demands so great, it is no wonder people are unhappy.

Both our government and healthcare system have undergone radical changes in expectations and purpose without a corresponding change in their structure. Those who designed these systems had fundamentally different ideas about what these institutions were meant to accomplish. Smart people can act like imbeciles, and vice-versa, when you change the rules.

Happy Thanksgiving

2011-11-23T20:52:00.000-08:00

If you think Independence Day is America’s defining holiday, think again. Thanksgiving deserves that title, hands-down.
~Tony Snow

Best wishes to all for a happy and healthy Thanksgiving.

You Can't Understand the Supreme Court vs Obamacare Without a Scorecard, So I Will Give You One.

2011-11-17T15:19:00.000-08:00

Supreme Court arguments and decisions are fascinating to a few of us and really pretty boring to most.

Dan Abrams

As predicted, the Supreme Court will render a decision about the Constitutionality of Obamacare, prior to the 2012 election. They have also allotted an extraordinary five-and-a-half hours for oral argument, presumably in deference to the unprecedented import of this decision. Besides the individual mandate, the Court has chosen to render three additional opinions, one of which has huge importance. I feel the judges are being unusually thorough because they clearly appreciate the stakes involved, and wish to anticipate future legal challenges.

The Court has four liberal judges who will support the bill and four conservative judges, who could oppose it, with justice Kennedy(known as the great flip-flopper) having the deciding vote. In addition to the legal considerations, the judges will be concerned about the potential negative reaction to overturning such a major act of Congress. The Court was subject to extremely negative publicity following the Bush vs Gore election verdict, and is aware how their rulings about desegregation and abortion have had enduring societal ramifications . Justice Kennedy has always shown concern about public reaction, and should be unwilling to overturn the bill due to such considerations. Furthermore, Judge Roberts, a conservative, has long been open to the concept of increasing government power, so he may vote against overturning as well. I suspect the vote will be 6-3 to uphold Obamacare.

The four areas they will decide are:

Whether Congress has the power to enact the individual mandate. – 2 hours
Whether the challenge to the individual mandate is barred by the Anti-Injunction Act. – 1 hour
Whether and to what extent the individual mandate, if unconstitutional, is severable from the rest of the Act. – 90 minutes
Whether the new conditions on all federal Medicaid funding (expanding eligibility, greater coverage, etc.) constitute an unconstitutional coercion of the states. – 1 hour

I will discuss each separately:

As I have previously stated, the individual mandate involves an arcane interpretation of the commerce clause of the Constitution, with little prior legal precedent. Although the Republican candidates have chosen to emphasize this aspect of the law in their opposition to Obamacare, there is little chance of overturning such major legislation over such a minor legal issue. The entire argument centers around whether the mandate is actually a tax, or not. Such a semantic issue is not grounds to overturn a bill of this magnitude.

The Anti-Injunction Act deals with suing about a tax before one has to actually pay it. This is a technical issue raised by one of the appeals judges. Although of interest to lawyers, this will have no material impact on the decision.

The question of whether the individual mandate is severable is another technical issue. If the mandate is unconstitutional, can the rest of the law be enforced? Although of interest legally, without the mandate, Obamacare funding falls apart. Without the financing in place, the entire bill is untenable, and could not be implemented. No matter what they decide on this issue, if the mandate is not enforceable, there will be no Obamacare.

The most interesting point raised is number four. Do the new requirements imposed upon the states to fund Medicaid exceed the federal governments power? Can Congress force states to raise taxes, fire teachers, and free prisoners to fund Obamacare? Although the Court will hear this argument, previous decisions have upheld such extensions of federal power. The Supreme Court will not overturn the legislation over this argument. However, this issue may well be the most important result of the legislation, with unintended consequences that will tear out country apart. More to come.

The Real Purpose of Medical Billing

2011-11-14T10:35:00.000-08:00

Patients sometimes get better. You have no idea why, but unless you give a reason they won't pay you.

Dr House

Dr Ezekiel Emanuel, Rahm's brother, and a medical oncologist, laments in a New York Times article about the billions of dollars “wasted” on medical billing. Although I do not question his medical credentials or family connections, he totally misses the point. Medical billing is only secondarily about the money, medical billing is in reality a market efficient mechanism that ensures quality, documents treatment, reins in out of control physicians, and offers patients choices. Medical billing is complicated because humans are complicated, and the expense of making it cheaper would be far greater than any money saved. These are pretty extravagant claims, especially from someone who makes money from medical billing(disclosure), but they are true nonetheless.

Doctors are a unique, protected class that have the legal ability to offer any medical therapy they choose, whether it is helpful, harmful, or just plain silly. A physician can treat your pancreatic cancer with organic tumeric, order weekly MRI's scans for headaches, perform 20 plastic surgery procedures at once, or give you Propofol to sleep. The only way that Medicare or insurance companies can ensure that treatments conform to problems is through billing rules. With tens of thousands of disease entities, diagnostic studies and treatments, and endless individual variation, it is impossible to issue rules and protocols to cover every encounter. Instead, the CPT code system for diagnosis, and the subsequent payment schedule, make certain that appropriate tests and therapy are performed for a given problem. As Dr. House says, you can decide to do things for no reason, but you won't get paid. Physicians who practice outside of accepted parameters are rapidly identified, and penalized. Replacing this mechanism with a system of rules, committees and monitors, designed to watch what physicians do, would be a bureaucratic nightmare that would make Obamacare look good.

Additionally, the billing diagnostic and treatment codes represents the core information in the medical record. For many medical issues, ones needs know little more than what is contained in the billing record, “ low back pain treated with 10 sessions of physical therapy”, is far more precise than several pages of specific history. Virtually all of the “benefits” that Obama or Emmanuel claim can come from electronic medical records, including treatment evaluation and demographic data, are contained in billing records, which have been electronic for years. Requesting a payment requires accurate, specific, and concise descriptions that rationalize the reporting procedure. CPT and treatment codes represent the DNA upon which medical records are built upon, and the best electronic medical record systems reflect this connection.

Finally, medical billing is the only mechanism that ensures people can get the care they want. Insurance plans differentiate themselves, and determine costs by choosing what they pay for, or not. One insurance plan may offer easier access to specialists and faster decisions on elective surgery, at a higher cost. Medical billing is the tool that offers the ability to differentiate between plans and levels of care. A single middle age person has far different medical needs than a young family or elderly diabetic, and one plan will never fit all. Different people will choose different ways to spend their healthcare dollars, and we need the ability to pay for different services to reflect that choice.

Medical billing fulfills many functions that Dr. Emanuel doesn't appear to understand, or even appreciate. Like many other “experts” in healthcare reform, one can be quite knowledgeable about one field, and clueless about another. This inability to grasp the complexity of our healthcare infrastructure permeates the debate about reform, and represents the greatest failing of Obamacare. Maybe we need to extend our medical billing process to “reformers” and “experts”. If they don't give good reasons for doing something, they won't get paid, or asked to write columns.

http://opinionator.blogs.nytimes.com/2011/11/12/billions-wasted-on-billing/?scp=1&sq=emanuel&st=cse

Can Walmart Reform Healthcare?

2011-11-11T12:03:00.000-08:00

"Wal-mart... do they like make walls there?" -

Paris Hilton

Walmart, the largest discount retailer in the world, has expressed an interest in supplying in-store healthcare . Clinics, with nurse practitioners or family doctors would give basic, walk-in care at Walmart prices, for the under-served, under-insured and under-funded. This large corporation hopes to transform healthcare in a manner similar to the way they remade retail commerce. The need cannot be denied, cost efficient healthcare has become the holy grail for reformers and politicians, and who better than Walmart to find a way? Surprisingly however, a way has already been found, one only has to drive a few miles from here to find a place where such low cost care is already being delivered.

Santa Ana, a nearby city, has a large undocumented immigrant population. On every corner is a Spanish language storefront doctor's office or health center offering a combination of modern medicine and traditional healing. The people frequenting these facilities have medicaid, or no insurance at all, and pay cash. I suspect they are not even counted in Obamacare projections, and must be added to the proverbial “30 million uninsured”. The type of care rendered harkens back to a earlier time, with physical examination, generic medications and the tincture of time taking the place of CT scans, breakthrough drugs, and specialists. Problems that persist, or do not respond, are sent to emergency rooms, and become the problem of the traditional healthcare system. Even if the quality of medicine is low, so are expectations, and the prices are Walmart low.

One would guess that with it's experience with lowering prices, Walmart could institute a better system, capturing both these patients and millions of others who lack insurance or family doctors. Nevertheless, I feel they will not succeed. Malpractice risk, largely ignored in discussions about corporate forays into medicine, represents an enormous and insurmountable barrier to implementing real reform and low cost care. Whereas the storefront offices are essentially immune from such risk, Walmart will be the worlds biggest target.

Individual clinics may not even carry malpractice insurance, and have no assets worth pursuing. Lawyers are reluctant to sue based upon the small likelihood of payoff. Walmart, on the other hand, is a the promised land for malpractice attorneys. Not only would the individual care be scrutinized to an unprecedented degree, the company would also be subject to class action suits and anti-trust regulations. Law firms would be lining up to dissect every policy and procedure suggested by the corporate office. Juries who might sympathize with a doctor would happily penalize an “evil” corporation for not finding an early cancer or missing a case of meningitis. Any recommended treatment that could be questioned by a medical expert would be contested in court until one jury renders the multimillion dollar verdict that destroys the entire experiment.

Malpractice reform is a prerequisite for the delivery of low cost care. Doctors must be guaranteed that if accepted treatment protocols are followed, then safe harbor should be granted. Such reform would make low cost care not only possible, but likely. Without this reform, Congress, Obamacare, or even Walmart, will not succeed.

http://www.npr.org/blogs/health/2011/11/10/142156478/wal-mart-plans-ambitious-expansion-into-medical-care

Where Have All the Engineers and Scientists Gone, Long Time Passing? Gone to Medical School, Every One, Long Time Ago

2011-11-08T08:59:00.000-08:00

How will the United States stack up against global rivals in innovation? The president and industry groups have called on colleges to graduate 10,000 more engineers a year

New York Times

Pundits, newspapers and the President have lamented the shortage of American scientists and engineers. A recent article in the New York Times clearly articulates the problem, but in typical media fashion, completely misses the point. Those potential scientists and engineers, who in the past have energized the American economy, have all gone to medical school. After medical school, they become medical specialists, a process that has both transformed medicine, and accelerated the escalation of healthcare costs. Although this trend has been in effect for many years, the recent great recession has exacerbated the problem, medical school applications are higher than ever.

Going to medical school is the default choice for the best and brightest with any science talent. Medical school offers a defined career path, with no real risk or uncertainty. The intellectual challenge is one of volume, not conceptual difficulty. One doesn't need to be able to invert a matrix or comprehend group theory in order to become a doctor. If one is willing to do the work, most better students can master the material, and everyone is pretty much guaranteed a lucrative career. This is in contrast to a career in science or engineering, which is characterized by an indeterminate period of training, real competition, capricious job prospects, and the ominous prospect of being outsourced to India.

These thousands of scientifically talented, high scoring, and hard working individuals are not satisfied with the often mundane routines of primary care. Instead, they are drawn to the more intellectually challenging and lucrative sub-specialties like Radiology and Neurosurgery. These individuals have brought us breakthroughs in both the quality and availability of specialized care everywhere in our country, but they also have lead to increased utilization and escalating healthcare costs. Not only has this shift away from science and engineering handicapped American competitiveness, but it has also become a key issue in the impact of medical costs on our economy.

Obamacare, and healthcare “reform”, by limiting the compensation of specialists, and encouraging primary care, will also discourage the scientifically talented from attending medical school. Why look in a screaming kids ears all day when you could be designing iphone apps? That is the question I posed to my kids when they me asked about medical school. Maybe you should say the same to yours. It could be good for the country.

http://www.nytimes.com/2011/11/06/education/edlife/why-science-majors-change-their-mind-its-just-so-darn-hard.html?scp=3&sq=engineers&st=cse

It Was The Best of Care, It Was the Worst of Care

2011-11-04T12:11:00.000-07:00

Anyone who isn't confused really doesn't understand the situation.
Edward R. Murrow

Here are some common statements about healthcare in America that are frequently cited

1) We have the best healthcare in the world

2) The USA ranks 41 out of 45 industrial countries in infant mortality

3) The USA has much higher cancer survival rates than Canada or Britain

4) The USA has 50 million uninsured

5) The number of deaths from prescription pain killers is at an all-time high

6) The number of drug addicts is at an historic low

Surprisingly, all of these statements are true. In the extraordinary complex world of American healthcare, these seemingly incongruous facts can co-exist without contradiction. Such a variegated landscape is impossible to easily encapsulate in headlines or soundbites. This difficulty with reducing healthcare reform to banal cliche may explain the abysmal quality of both the political debate and press coverage. Before we can fix our problems, we need to understand them, but that requires both intelligence and uncompensated effort. Additionally, the amount of money, ego, and political advantage tied to healthcare reform has tainted almost every opinion and expert. No only does everyone has as “point of view”, but they also have a bought and paid for bias that undermines trust and makes true reform a far off dream.

These problems are compounded by our dysfunctional and corrupt political landscape. Our leaders, the press, and many “experts” have abrogated their duty and have instead resorted to canards, ideology and disingenuous attempts to distort reality and pretend away reality with bogus assumptions and magical technology. Real reform requires that brutally honest choices be made about what healthcare our society chooses to pay for, and what we will not. The route we have chosen, cutting fees for hospitals, doctors and drug companies, without appreciation or consideration of the consequences, will reverberate in unforeseen and possibly catastrophic ways.

So if you are confused about healthcare reform, don't be dismayed. Anyone who isn't confused either doesn't understand or is lying, possibly both. I suggest that is a pretty good definition of a politician.

Here is a brief explanation of the 6 points above

1) We have the best healthcare in the world(How many Americans go to Canada, Cuba, or Singapore for cancer chemotherapy or hip replacements?)

2) The United States ranks 41 out of 45 industrial countries in infant mortality(this is very complicated, with important differences about how premature deaths are counted, as well as genetically determined population differences, see post from 3/7/11.

3) The USA has a far higher cancer survival rate than Canada or England(your chance of surviving cancer 5 years is as twice as high as someone from Britain)

4) The USA has 50 million uninsured people(most of them still get medical care, although not necessary the care they want)

5) The number of deaths from prescription pain killers is at an all-time high(mainly from oxycontin)

6)The number of drug addicts is at an historic low(addiction rates were far higher in the late 1800's, and have been dropping steadily since the 1960's)

Can You Fix Bad Regulations with more Bad Regulations? Maybe Not

2011-11-01T12:07:00.000-07:00

Furious activity is no substitute for understanding.
H. H. Williams

Politicians are the same all over. They promise to build a bridge even where they is no river. ~Nikita Khrushchev

Many crucial drugs are in short supply, which threaten the life and health of thousands of Americans. Procedures and treatments are being delayed or canceled, and many expensive hours are wasted trying to locate these pharmaceuticals. Entrepreneurs, some of them unscrupulous, have exploited these shortages by buying and reselling these drugs for a profit. Needless to say, this is a situation that needs to be addressed. President Obama, has issued new regulations designed to to remedy this problem, but these regulations show a profound lack of understanding about the reasons for these shortages, and are certain to fail.

Doctors are taught that understanding a problem is the first step toward solving it. Why are these drugs in short supply to begin with? Drug companies, faced with decreasing compensation for their drugs due to healthcare cutbacks, can no longer profitably produce many of these off-patent or rarely used medicines . Additionally, government regulations have dramatically increased the cost of drug production. Most of these pharmaceuticals are produced in older factories which do not meet new codes, and cannot be updated without great expense. Some companies continue to make many of these drugs anyway, but as cost pressures mount, more effort will be placed into those drugs which make money. Even if these companies were paragons of virtue, as compensation decreases, the incentives will become overwhelming.

Unfortunately, Obama's regulations do not address the real problem. These new rules mandate that shortages are discovered earlier, and increase spending for more government agents, but don't increase drug production. His plan makes no effort whatsoever to address the underlying issues or to prevent further erosion of the production landscape. Much like Obamacare, the response represents a bureaucratic, simplistic, and fundamentally misguided response to a very complex problem.

To the man with a hammer, all problems look like a nail. Politicians, unable or unwilling to understand the complexities of our healthcare crisis, respond with furious activity with little or no possibility of success. Promising to build another bridge to nowhere will not solve our drug shortage, nor fix our healthcare crisis.

What Toll Roads Can Tell Us About Medicaid, and Healthcare

2011-10-29T12:01:00.000-07:00

If we're looking for the source of our troubles, we shouldn't test people for drugs, we should test them for stupidity, ignorance, greed and love of power.
P. J. O'Rourke

There is an underused toll road near my house that loses money every year. The appointed geniuses who run things respond by raising fees annually. As the tolls go up, even fewer people use the road, so it loses even more money. The obvious answer is to lower the tolls, which would increase utilization, and result in far more revenue. The continued nonsensical behavior of our leaders suggests that lowering fees violates some bureaucratic canon they all must swear to uphold during some occult indoctrination. I am resigned to the fact that we will forever be cursed with a new, partially empty highway in the land of terrible traffic jams.

The same disordered thinking prevails in the hallowed halls of those who administer Medicaid in California(we call it Medical). After a nasty legal battle, the authorities received permission to cut fees to providers another 10%. This will lower the payment for a minor office visit to about 11 dollars(if you get paid). This amount of money barely covers the cost of sending the bill the three times required to receive reimbursement. Authorities project that this cut will save hundreds of millions of dollars for Medicaid, but the actual impact is far more complicated.

First, those doctors that continue to take Medicaid patients will tend to increase the intensity of their treatments, usually by up-coding. Turning a limited visit into a comprehensive one can be accomplished easily, and when the compensation gets so ridiculously low, the incentives are overwhelming to pad the bill.

A more important impact will be a further reduction in the number of doctors willing to see Medicaid patients. In many areas, it is already virtually impossible to find anyone willing to treat the indigent, and these cuts will accelerate this trend. Even more patients will be diverted to emergency rooms who cannot refuse them. Emergency rooms are poorly equipped to efficiently treat these people, who often present with chronic problems. When one has no history or knowledge of a patient, providers are obligated to do extensive evaluations for every visit, which is expensive, redundant and wasteful. So although Medicaid may show some reduction in expenses, overall healthcare costs will increase, and simply be shifted to emergency rooms and private insurance.

A better solution might be to raise Medicaid payments to physicians, with an additional bonus if emergency room visits were reduced and hospitalizations avoided. Aligning incentives for doctors and patients to render care inexpensively would both save money and improve the quality of the healthcare. However, that might require testing our leaders for “stupidity, ignorance, greed and love of power” before we elect or appoint them, and there may be no one left to lead.

The Illogical Logic of Healthcare Reform

2011-10-28T14:51:00.000-07:00

A growing number of states are sharply limiting hospital stays under Medicaid to as few as 10 days a year to control rising costs of the health insurance program for the poor and disabled.

- Kaiser Health News

Three fundamental pillars of healthcare in the United States are Medicaid, rural hospitals and inner city emergency rooms. The bean counters, lobbyists and politicians who cobbled together Obamacare did not care, and could not understand, how their politically motivated machinations could destroy these pillars, causing a catastrophic failure of the healthcare system. Recent reports about how bureaucrats are responding to Medicaid cutbacks illustrate the degree of system dysfunction, and how divorced from reality healthcare reform has become.

Obamacare, in order to meet it's fairy tale like financial projections, requires substantial increases in the number of people eligible for Medicaid, while simultaneously decreasing federal funding for the states. Hence, almost all of the financial burden will fall upon bankrupt state governments. The administrators and accountants in charge of state budgets have responded with typical bureaucratic delusion by “limiting” the number of days a patient can stay in the hospital. Reminiscent of black comedy or satire, this rises to the level of the criminally absurd. “Sorry Mr. Jones, although your wife has peritonitis, is receiving 3 antibiotics, and needs a respirator, but she has been in the hospital 11 days and needs to go home”. Needless to say, in the universe the rest of us live in, this will not happen. Hospitals and doctors will treat such patients without compensation, and lose money. In the past, uncompensated care was subsidized by higher charges for paying patients. Sadly, such cost shifting only works as long as insurance reimbursement actually covers hospital expenses. However, with Obamacare, even these payments will be reduced substantially. Providers cannot lose money on every patient but “make it up on volume”.

Unfortunately hospitals and doctors are not like the Congress. They cannot print more money, raise the debt limit, and work as a lobbyist when you lose the election. When medical care providers cannot pay the bills, they go broke and close. The impending failure of Medicaid, hospitals, and healthcare providers caused by the politically motivated, financially ridiculous, and medically irresponsible Obamacare legislation is coming closer by the day. Maybe Congress can pass a law restricting the number of days people can be sick, that would go a long way toward lowering healthcare costs, which makes as much sense as limiting hospital stays.

http://www.usatoday.com/news/washington/story/2011-10-23/states-limit-medicaid-hospital-stays/50886398/1?csp=ip

Don’t get caught with your claims down on January 1, 2012 because of 5010

2011-10-26T18:25:00.000-07:00

Beginning on January 1, 2012, a federal mandate requires health plans, clearinghouses, and providers to use anew electronic format (5010) for claim submission, remittance, eligibility, and claims status requests and responses. Insurance carriers that are 5010-ready will deny claims that are not submitted in 5010 format after January 1, 2012.

Why do we need 5010?

The most widely recognized change in 5010 is allowing EDI transactions to differentiate between ICD-9 and ICD-10. Upgrading from the current HIPAA 4010A1 transaction format to the new 5010 format addresses several key goals, such as

Increase transaction uniformity
Support Pay for Performance (ICD-10, the diagnosis format that goes live 10/1/2013)
Streamline reimbursements

What do we need to do to prepare for the 5010?

To prepare for 5010, we need to test our technology for meeting the new standard.
Rolling out any new technology takes a very disciplined approach to minimize the risks of payment delays. Testing this long before a deadline is crucial for our providers and their patients.
Today, the carriers provide the option to test 5010 while allowing the rollback to 4010 if needed. So any error discovered during the test, can be quickly handled by rolling back to 4010 to minimize the payment delay. This option will not be available after January 1, 2012. Therefore, it’s imperative to complete the testing prior to January 1, 2012.

Insurance companies profit on the float - the longer they keep the money they owe you, the greater is their profit. The complexity and the errors resulting from any transition provide another opportunity to delay and deny claims.

Don’t get caught with your claims down on January 1, 2012 because of 5010!

On Complexity, the Gordian Knot, and Obamacare

2011-10-24T10:15:00.000-07:00

Gordius dedicated his oxcart to Zeus, tying it up with a peculiar knot. An oracle foretold that he who untied the knot would rule all of Asia.
Alexander, stepping back, called out, "What does it matter how I loose it?" With that, he drew his sword, and in one powerful stroke severed the knot.
From “The Life of Alexander”

Occupy Wall Street, the Tea Party, our dysfunctional federal government, clinical depression, a failing economy, unemployment, inequality, religious fundamentalism, failed nations, and Obamacare can all be traced to the same societal trend: complexity. Increasing complexity in society, economy, politics, and medicine lies at the root of all of these diverse, yet related, human changes. As our population grows and knowledge grows exponentially, the capacity of our individual brains, institutions, political systems, and religions to understand, control, legislate and explain diminishes. These physical symptoms, economic dislocations, political movements and religious conversions are visceral, naïve, and ultimately useless attempts to annul or roll back the inevitable.

Until the last 50 years, large portions of our society could still lead a life on the farm or assembly line which was fundamentally little changed for many thousands of years. Even the family doctor could master most of what medical science there was. However, as complexity increases, those people and institutions unable to cope will be left behind, while those who can understand and respond to complexity will thrive. This is why neurosurgeons, hedge fund managers, patent attorneys, microprocessor chip designers, Singapore and Apple are doing just fine, while high school drop outs, assembly line workers, our educational system, Greece, Blockbuster and Congress are having a very hard time. Unfortunately, the losers in the new order are often resistant to change, and refuse to make the effort to understand and address the complexity they are facing. People and institutions resort to simple solutions and nostalgic hopes because they are unwilling or unable to face the reality of the present situation.

Obamacare can be considered another such doomed nostrum. Refusing to confront the byzantine complexity and irreconcilable ethical dilemmas of modern medicine, Congress instead relied upon the unproven technology and fanciful promised efficiency savings. They accepted to duplicitous assurances of deeply conflicted interest groups and corporations to guarantee Mercedes care at Yugo prices. In the end the bill is little more than magical thinking on a grand scale, ignoring the incomprehensible complexity of a elaborate, but tenuous, multi-trillion dollar industry.

Alexander and the legend of the Gordian knot is famous in part because it demonstrated how a penetrating and bold intellect could solve a problem of infinite complexity quickly and dramatically. Unfortunately, as the supporters of Obamacare will soon learn, it is much easier to cut a rope apart than to tie it back together.

The Most Rampant Drug Abuse of All

2011-10-22T10:30:00.000-07:00

The prescription pad kills more people than guns in this country

John Burnham MD

The person who takes medicine must recover twice, once from the disease and once from the medicine.

William Osler, M.D.

A recent report that 1 in 10 Americans takes antidepressants, as well as the Conrad Murry trial, underscore a unappreciated problem with prescription drug use in this country. Most people are aware that there are unscrupulous doctors who sell pain killers for profit. What people do not understand is the widespread misuse of other medications improperly prescribed by well meaning, but inexpert, physicians.

Having a medical degree does not make you proficient in administering the thousands of drugs now available. Every licensed physician can legally dispense almost any medicine, even ones they are woefully unfamiliar with. Modern drugs can remedy a wide variety of previously untreatable conditions, but must be used correctly, dosed properly, and can have severe, or even fatal side effects. Powerful medications require extensive experience to understand the subtleties of their use. The Conrad Murray trial demonstrates a particularly egregious case of misuse of a drug, leading to death, but a similar, if less dramatic problem, is far more widespread.

At least 30 million Americans are now taking antidepressants. The statistic is amazing in it's own right, indicating something about the mood of our country. However, the fact that surprises me most is that at least 90% of those prescriptions are written by internists, family doctors, and gynecologists. Symptoms are common, and it is easier to give an antidepressant, which insurance will pay for, than to refer people for therapy, which might not be covered. Unfortunately, these practitioners frequently give the wrong drugs, for the wrong symptoms, in the wrong dosages. People don't get the benefit of the treatment, but still keep taking these drugs.

Antidepressants dosage needs to be carefully titrated, with response, symptoms and side effects followed closely. Proper administration requires frequent and multiple visits, which insurance will not cover. If the treatment is ineffective , drugs need to be changed, or discontinued. Many of those 30 million people are not getting the full benefit from the therapy, or are taking these medicines uselessly.

Many suicides occur in patients already taking antidepressants. I wonder how many of these result because people are taking the wrong dosages, or the incorrect drug. It is enough to make you depressed.

Obamacare, Ego, and Our "Transformational" President

2011-10-19T10:54:00.000-07:00

All the President is, is a glorified public relations man who spends his time flattering, kissing and kicking people to get them to do what they are supposed to do anyway.

Harry S Truman

When a self-made billionaire talks, I tend to listen. Mort Zuckerman made an interesting observation about healthcare reform and Obamacare, pointing out the distinction between cutting costs and increasing coverage. He also asserted that Obama chose to pursue increased coverage in order to be considered a “transformational” President. In other words, our chief executive concentrated upon the less difficult, and less vital, aspect of reform for his own selfish reasons. The point is well taken.

Although I would add “quality” as a third component of reform, Zuckerman's concept is useful. Obama and the Democratic Congress based their justification for the legislation on the need to increase healthcare coverage. Citing the frightening number of uninsured Americans, Obamacare's primary thrust was to include everyone, leaving cost control to unspecified bureaucratic committees and unproven technology. This concentration upon lack of coverage overstates the problem, and the refusal to confront costs guarantees the failure of the entire program.

The lack of insurance can lead to extreme personal hardship and financial ruin. However, even these uninsured receive care in this country. Our ad-hoc safety net of emergency rooms, Medicaid, and uncompensated care provide medical treatment for these people, if inelegantly. A homeless person in downtown Detroit with cancer can still received therapy. Furthermore, for many of our younger, healthier citizens, now subject to the mandate, insurance coverage is a bad financial choice. Their expected medical costs are far less than the price of the insurance, and they are willing to accept the risk. One has to consider the number of uninsured who are simply making a rational decision.

Increasing costs, on the other hand, threaten to bring down the entire healthcare system. The unrestrained growth in medical expenses during a time of severe recession is unsustainable. Obamacare, exacerbates this problem by encouraging increased utilization without appropriate cost controls. The savings projected due to electronic medical records are utter fantasy, and the committees charged with restraining spending are subject to extreme political and societal pressure. The required healthcare rationing will take time and study, which we simply do not have.

Costs can be controlled, but will require real reform. I have suggested a two tier system with a limited benefit basic insurance package and safe harbor legal relief. However, by choosing ego and grandiosity over reality and practicality, Obama and the Congress have delayed any resolution by many years. Obama should have listened to Harry Truman, promised less, and told us the truth.

http://online.wsj.com/article/SB10001424052970204002304576628673446417268.html

Obamacare Begins to Unravel, or You Can't Make a Camel into a Horse

2011-10-15T15:45:00.000-07:00

Reality is merely an illusion, albeit a very persistent one

--Albert Einstein

A Camel is a Horse Designed by a Committee

--Anonymous

Like a house of cards, or the game of Jenga, one of the foundation blocs of Obamacare has been pulled out. The long term health insurance component of the reform legislation has been axed by the administration because too few people signed up. This episode highlights both the extreme difficulties of true reform, as well as the cynical and deceitful assumptions promulgated by the proponents of Obamacare. The projected cost savings promised in the bill required millions of healthy patients to pay high premiums for long term coverage that most would never need. The failure of this particular program demonstrates how “hope and change” based upon wishful thinking is bad policy and doomed to fail.

Chronic care insurance is problematic for a number of reasons. Besides being expensive, it represents another source of “market failure”. Healthy people are unlikely to need the insurance for many years, leaving only the sick and elderly as customers. Without premiums from everyone, the cost becomes prohibitive, and the entire concept does not work. Passing an additional “mandate”, forcing everyone to pay for long term insurance was politically impossible, so the administration disingenuously assumed that enough healthy people would sign on to make the projections work.

Unfortunately, for the supporters of Obamacare, the “savings” generated by this long term program are vital to budget forecasts. The failure of this initiative means additional costs, and larger deficits. More importantly, this is just the first example of the blatantly fraudulent costs assumptions underlying the legislation itself. No matter how noble the motivation, magical thinking cannot make reality vanish for long, or turn a camel into a horse.

http://www.washingtonpost.com/national/health-science/white-house-kills-long-term-care-program/2011/10/14/gIQAVZLYkL_story.html

You Can Have Wall Street if You Give Me Obamacare

2011-10-11T09:28:00.000-07:00

We have people speak, everyone votes on it and we come to an agreement. And that's how we want society to be.

-- Occupy Wall Street

Although I wasn't a typical 60's radical, I spent some time protesting the Vietnam War. Watching the Occupy Wall Street protesters awakens many conflicting memories from that difficult time. Ironically, some of the lessons I learned participating in demonstrations explain how legislation as deeply flawed as Obamacare could get passed by seemingly reasonable people. As these new protesters will soon learn, inclusive democracy leads to unexpected outcomes.

Sincere and justifiable anger at societal abuse draws together the true idealists and the frustrated powerless, as well as the naïve and easily mislead. The desire for inclusiveness and equality gives voice to all, whether informed, biased, silly or stupid. Complexity, intricacies, and the resultant unintended consequences, are beyond the capacity of such groups to comprehend or confront.

Furthermore, single issue groups, with narrow agendas regarding gender, racial or economic issues, with their monomaniacal members, soon dominate the situation. I can remember how our “demands” expanded from ending the Vietnam War to include racial justice, gender equality, subsidized food prices, support for workers, and freeing the Chicago 7. “Bringing everyone to agreement” actually means including multiple independent agendas, with little regard for the reality of their implementation.

The adoption of Obamacare was a similar process. The President and Democratic Congress were originally motivated by a sincere desire to address our healthcare crisis. However, they lacked the intellectual ability or moral courage, to comprehend and address the byzantine complexity of actually fixing the problems. Instead they allowed the single issue power groups, big business, unions and the drug companies, to control the agenda and pass a partisan and unworkable bill that will certainly fail.

After participating in several demonstrations and marches, I realized that protesting and “street” democracy was not a particularly good way to get things done.

Good government requires expertise, intelligence and the ability to reject bad ideas, even if that offends some idealists. Maybe we need to elect a few more reformed radicals.

Whether Surgery is Necessary Depends on Who You Ask

2011-10-06T08:21:00.000-07:00

Righteousness is easy in retrospect.

Arthur Schlesinger, Jr.

A recent article from the Lancet presents some very disturbing statistics about surgery for people nearing death. One in three Medicare patients had surgery in the last year of life. One in five had surgery in the last month of life, and one in ten had surgery in the last week of life. The obvious point is that these surgeries were not very helpful, and may have caused further pain and suffering. Although the article purports to offer both sides of the issue, the underlying bias is clear: “Those greedy, uncaring doctors are operating on terminal patients for the money, and driving up Medicare costs to boot”. As my readers may have already guessed, I have a different perspective.

The paper, and the underlying bias of the audience, is falling victim to the retrospective fallacy(a favorite of mine). One must realize that although some of the patients who had surgery died within a year, most did not. In fact, for most people, surgery was effective and helpful. No one, not the surgeon, family doctor, or Obamacare bureaucrats, can tell which patients will benefit and who will die prior to the operation. One can quote statistics about the outcome of a intervention, but for the individual patient, the outcome is 100 percent, it either works, or it does not. As one does not know beforehand whether the procedure will work, how can one ethically refuse a lifesaving operation that may only have a 66% chance of success?

Doctors face these dilemmas every day. Sometimes the odds are too long, the patient too sick, and the operation too difficult. Those cases are easier. Most of the time, one does have something to offer the patient, with a chance of major benefit, even return to a normal life. If the patient and family wish to proceed, it is difficult, and morally wrong, to say no. Most older patients do not wish to die, or suffer pain needlessly, even if it costs a little more.

This conundrum points out the conflict between the societal desire to cut costs, and the individual imperative to extend life. This dichotomy lies at the center of the debate about healthcare reform but is not being mentioned by the cowardly and disingenuous politicians and "reformers" who rammed Obamacare through Congress. Righteousness, even in retrospect, will require a little more brutal honesty.
http://www.nytimes.com/2011/10/06/health/research/06medicare.html?_r=1

A Bad Economy is Also Bad For Your Health

2011-10-04T08:54:00.000-07:00

Losing a job is more than just a financial crisis for people, it creates numerous other damage, stress, anxiety, substance abuse, fights and conflicts in the family and feelings of embarrassment and depression.

Carl Van Horn, a professor of public policy and economics at Rutgers and head of the Heldrich Center

.
It is a little known fact that 30% of American military recruits were rejected during World War Two because of physical issues. A substantial portion of these problems were related to malnutrition attributed to the Great Depression. This statistic reinforces our need to consider both the short and long term healthcare implications of our present economic woes. Although people are not yet starving in this country, widespread unemployment and economic dislocation have severe negative impact upon the health of Americans.

A recent article quoted above mentions many of these impacts. Stress, substance abuse and depression are clearly associated with increased medical problems and costs. The long term unemployed often fall into the ranks of the substance abusers, homeless, or disabled. Furthermore, the loss of medical insurance results in finding and treating diseases later, and at higher expense. As I have previously noted, our healthcare system has become the bottom string in our social safety net, and eventually will be obligated to care for these unfortunate individuals, at great cost.

Under Obamacare, these uninsured masses will be enrolled in Medicaid, presumably at the expense of the states. The fanciful Congressional projections used to justify passage of the bill anticipated neither high unemployment, nor the resultant medical impact. These massive, unanticipated, and unfunded medical demands, thrust upon already bankrupt states, will crash both the Medicaid program, and possibly the entire healthcare system. Reforming healthcare is difficult in good economic times, in our great recession, it may well be impossible.

http://www.businessinsider.com/the-recessions-silent-mental-health-epidemic-2011-10

Obamacare, It's Still About the Politics, Not the Medicine

2011-10-01T07:16:00.000-07:00

"Politics, noun. A strife of interests masquerading as a contest of principles.

Ambrose Bierce

I am back from Europe, and not surprised to see how little has changed. The Red Sox collapsed, the stock market is terrible, and the administration has asked for an expedited Supreme Court ruling on Obamacare. The decision will be rendered sometime in the early summer of 2012, at the height of the presidential campaign. Although the request is purported to be about resolving this contentious issue, the actual motivation is a brilliant, if devious, political strategy to get President Obama re-elected.

To set some background, the legal challenges to the legislation revolve around obscure interpretations of the commerce clause of the Constitution, and the mandate requiring purchase of medical insurance. I feel it is unlikely the Supreme Court will overturn such important legislation over such a minor judicial issue. My experts tell me the justices are extremely concerned about the damage done to the Court's reputation by the Bush-Gore election in 2000, and are unlikely to risk such exposure again. I expect a 6-3 vote to uphold, with justice Roberts in the majority.

The political game is both more subtle and compelling. Rather than criticizing the impact of Obamacare on medicine, virtually all of the Republican candidates have chosen to base their opposition on the Constitutional argument. Calling the bill unconstitutional appeals to the right wing of the party, which is concerned with limiting the size of government. Attacking the bill based upon it's actual impact upon the healthcare requires real understanding of complex issues, which are hard to summarize in a 15 second sound bite. What the Republican strategists do not understand is how this approach may backfire.

Obama's gambit will be to use the opinion of justice Roberts, a Republican appointed, highly respected conservative, to characterize his electoral opponents as out-of-touch extremists. “If justice Roberts himself agrees the bill is Constitutional, only a dangerous radical could oppose it”. This approach is both subtle and brilliant, and may well disarm one of the most important issues the Republicans have in the coming elections. Making his adversary appear foolish, and avoiding criticism about Obamacare will be worth many votes for the President.

Most disturbing to me, is that none of this has anything to do with healthcare. Obamacare is, was, and always will be about politics, not medicine. Instead of addressing the real problems with the lives of Americans, the bill has become a cynical battleground for getting elected. It's enough to make me want to go back to Greece, at least they all agree they are fighting about money.

Ode to a Grecian Bankrupcy

2011-09-24T04:46:00.000-07:00

Democracy passes into despotism

Plato

I have been on a Greek Island cruise (life is tough), which has restricted my postings due to a combination of news deprivation, limited internet connectivity, and alcohol. Nevertheless, I have observed how the Greeks are confronting their epic financial meltdown. They seem gripped by an air of resignation, conditioned by a long history of failures of their government and economy. Nothing prepares you for bankruptcy better than a prior one.

The specter of government failure is new to Americans. Although at times in our history the United States came close to collapse(the Civil War and Great Depression), our country always managed to rally back. However, the combination of severe recession, expensive wars, and the impending nightmare of Obamacare threaten our country in an unprecedented and frightening manner.

The exponentially increased in regulation the bill mandates, superimposed upon deep funding cuts, could cripple or destroy several pillars of our healthcare system. Dysfunctional and unequal as it might be, our medical infrastructure supplies the needs of most Americans. The politically motivated funding reductions in Obamacare will gut our Universities, Medicaid, and rural hospitals, destroying the unappreciated safety net that President and Congress seem shamefully unaware of. Without these pillars, the entire system may fall.

The United States is not Greece, we have never witnessed a debacle of this magnitude. A government precipitated failure of the healthcare system will have catastrophic impact upon politics, government, our economy, and the dream of what America might be. I truly hope we weather this crisis, but we need to keep Plato’s words in mind as it happens.

On Vacation

2011-09-22T20:17:00.000-07:00

I have been on a cruise of the Greek Islands with limited internet. I am back next week with a few new posts.

Repealing Obamacare, Is it Really That Easy?

2011-09-17T20:52:00.000-07:00

On account of being a democracy and run by the people, we are the only nation in the world that has to keep a government four years, no matter what it does.
Will Rogers

The Republican candidate debates have been more akin to political theatre than reality. They are designed to appeal to the narrow group of registered voters that participate in the primary elections. Nevertheless, Mitt Romney said something very intriguing. I have always thought that repealing Obamacare would require some kind of action from Congress, such as outright repeal or de-funding, taking substantial time and more rancorous debate. Romney instead suggested as President, could simply grant all 50 states “waivers”, and stop the implementation of the law immediately. This executive sleigh of hand had not occurred to me previously, but would probably work.

The executive trick of granting waivers has been used extensively by Obama himself, (usually to benefit his union supporters whose profit generating insurance plans cannot conform to the 80% benefit payout rule), so precedent exists. Some question remains about whether every state would request or accept the waivers. However, when faced with the titanic financial burden the unfunded portion of the law places on Medicaid and other state programs, I suspect every state will request such a waiver, whether they are blue or red.

There will be legal challenges by Obamacare supporters to such an executive order, which clearly usurps the power of Congress. Many legal arguments could be made on both sides, and Congress may eventually prevail. However, the appeals would take years, and time would render any eventual decision moot. Without the heavy hand of the federal government enforcing the law, the entropy of the status quo will triumph.

So a Republican president, with or without Congress has the power to unilaterally end the “affordable” healthcare act. Changing the law without the consent of the people seems undemocratic, but it does have a certain ironic symmetry.

Obamacare is a bad law, passed in secret, with the contents of the bill purposely withheld from the American people for months. Many of the most important components were not even decided, but instead were left to unelected bureaucrats for interpretation. Furthermore strong-armed tactics were used to push the legislation through Congress quickly over the objections of a majority of Americans, in direct contradiction to promises made by Obama himself. That’s not very democratic either.

More Hype on Computers and Medical Care

2011-09-13T12:06:00.000-07:00

“IBM's Watson supercomputer to give medical diagnoses “
reuters news service

“A computer makes it possible to do, in half an hour, tasks which were completely unnecessary to do before”

anonymous

I am pretty good at the game Jeopardy. However, I once met someone who actually won a number of times, who gave me an interesting perspective. He told me that all the top players knew the answers to most of the questions, so the real contest became a matter of who had the best reaction time. Winning the right to respond requires hitting the button precisely when Alex Trabek stops reading the question. If you hit the button too soon, you are disqualified, too late, and someone else gets to answer. So when Watson, the IBM computer trounced the human players, it was really a matter of the computer being able to time the the button more accurately than humans, not a matter of who was smarter.

Therefore, when I hear hysterical announcers proclaiming how Watson is going to revolutionize medical diagnosis, I just say “hmmm, not again”. TV shows like “House” tend to over-dramatize the process of diagnosing medical conditions. Being a Radiologist for 25 years, I know the the reality is far different. Common things are common, and the methods for diagnosing most diseases are pretty well established. Chest pain is most often heart disease, elevated blood sugar is diabetes. Abnormal findings on X-rays need to be clarified and confirmed with additional studies and tissue examination. Most diagnostic pathways have already been worked out by both experience and less powerful, but more dedicated, computers. Having Watson giving the same result a few seconds faster will really be of little help. True diagnostic conundrums do exist, but they frequently come from unusual signs or symptoms, lab tests that mimic other conditions, or incorrectly reported or interpreted examinations. I am not sure how Watson will help if the Radiologist misses the abscess on a CT scan.

Most importantly, most non-physicians do not understand the role of statistical certainty in medicine. I did thousands of biopsies in my career, and was frequently asked prior to the procedure: “what are the chances of this being cancer?”. At the beginning of my practice, I would give patients the odds, much like a computer would do. However, I soon came to the conclusion that the question itself was misguided. Later, I told people “you don't have 30%-50% of a cancer, you either have it 100%, or not at all, we will know after the biopsy, and talking about it before the results are back is irrelevant”. Once the question of a having a treatable cancer, or other serious disease is a real possibility, you need to know with certainty, the rest is just noise.

So although Watson may be able to tell you within a millisecond that your risk of cancer is 22.203%, it can't do the biopsy, tell jokes, make sure your get your pain medications, or reassure your spouse things are going to be alright. That's the hard stuff anyway.

Secular Vs. Cyclical Changes in Medicine

2011-09-10T18:52:00.000-07:00

In the financial markets, analysts generally distinguish between secular and cyclical trends. The former refer to powerful, long-term directional moves, while the latter represent shorter-term swings around the primary trend

Economic textbook

If you are trying to fix a problem, it usually helps to understand it. One of the biggest barriers to solving our healthcare crisis is the failure of those in power to comprehend the true nature of the forces transforming healthcare. The changes in medicine are secular, but the solutions being offered are cyclical. Both political parties, as well as most economists and pundits, are offering short term solutions for long term problems. Until the President, Congress, and the policymakers grasp this unfortunate reality, all reform efforts are destined to fail.

Fifty years ago, during the Marcus Welby era, your family doctor could single-handedly discover, diagnose and treat your problem, if it was one of the few diseases he knew how to treat. However, if you had coronary artery disease, most cancers, a degenerated knee, or thousands of other problems, you were out of luck. The fact that so few treatment options were available limited the cost of care, but left many to suffer without hope.

Since that time, modern medicine has piled advance upon advance, which when taken together have resulted in a secular change. Not only can many more diseases be treated, but the intensity and subsequent cost of those therapies has exploded. Myriad cancers, arthritis, diabetes and its complications, lung, kidney, liver, and heart problems can now be remedied. However, such diseases are rarely completely cured, and instead become chronic conditions, requiring long term, highly specialized, and very expensive care. Much of the increasing cost of healthcare is directly related to the continuing needs of chronic conditions. One patient's yearly supply of remicade(for Ulcerative Colitis), would have paid for Dr. Welby, his office and his nurse.

The mandates of Obamacare, as well as those suggested by most reformers, still view these problems as cyclical in nature, fixable by incremental changes. These nostrums assume that small adjustments to the fees paid, or reducing the price of the drugs, is all that is required. However, as I have argued previously, any such impact will be minimal. Not paying doctors at all, or nationalizing drug companies, would barely slow the increase in healthcare costs. Medical technology has progressed to the point that there is virtually no limit on the amount of money that can be spent screening for problems, treating chronic diseases, replacing joints, transplanting organs, and addressing untold numbers of physical and psychological complaints, real or imagined.

True reform will require hard decisions about how much care can be given at what cost, and setting limits to how much insurance companies, the government, and the individual will pay for that care. We can no longer pretend that every person living in our country is entitled to the unlimited and exponentially expensive care that our medical edifice is capable of rendering. Secular changes require secular solutions. Denial might get you elected, but it won't fix healthcare.

Automated Reminder Calls as a Marketing Tool for your Practice

2011-09-10T01:40:00.000-07:00

By Zsolt Halmos, CEO, ReminderCall.net

In a difficult economy, affordable publicity becomes the lifeline of small businesses. If you are already providing automated reminder calls, you are providing a valued service and projecting a cutting-edge image. Did you know you can also use automated reminder calls to grow your practice? Here’s how to add inexpensive and effective automated reminder calls to your marketing arsenal:

Focus on the patients you already have. Generating repeat business is far easier than trying to find new patients. Sending promotional phone calls to past clients is an easy and effective way to get referrals and book more appointments.
Create a sense of community. Use automated reminder calls to invite patients to an Open House celebrating a holiday or company milestone. Give out refreshments, product samples and discount coupons. Be sure to invite local physicians.
Have your existing clients bring in new patients. Use automated reminder calls to create a Refer-A-Friend promotion and increase your client base. Reward the referring patient with a discount or a promotional giveaway.
Offer a free class. Use automated reminder calls to invite patients to attend a free class about exercise for weight loss, proper back care, or pain management.
Use automated reminder calls to promote friendly relationships with your patients. For example, send out birthday greetings that include a discount.
Generate a buzz. Use reminder calls to enhance your online marketing. Announce webinars, podcasts and your presence on social network sites or blogs.
Increase patient loyalty. Do you have many Spanish or Mandarin-speaking patients? Use automated reminder calls to communicate with them in their language of choice.
Improve patient compliance. Allow patients to sign up for automated exercise reminders.
Remember to always project a professional image. Use a pleasant tone, professional vocabulary and words like courtesy call to deliver a message that feels like a courtesy to your clients.

These are just a few ways to use automated reminder calls to grow your business. Best of all, you get to avoid ineffective postcards that end up in the trash, unopened emails that cannot get past spam filters and print ads that are simply too costly. You are virtually guaranteed that someone will receive your message, either in person or on an answering machine, for less than the cost of a stamp!

For more information visit www.remindercall.net.

Time to Reconsider Obamacare and the Economy

2011-09-07T10:29:00.000-07:00

They are led by an invisible hand to make nearly the same distribution of the necessaries of life

Adam Smith

Selective memory is one of the deep ironies of American politics. As our economy careens from one crisis to another, Obamacare, the dominant story of 2010, has dropped off the radar. The President, Congress, and the press have seemingly forgotten how healthcare reform was to be a key aspect of America's economic transformation. Proponents of the legislation don't mention the bill at all, and opponents suggest repeal at the end of speeches. During the “debate” about the legislation, extravagant projections about jobs gained or lost were casually offered, only to be conveniently forgotten now that the bill is passed. It is time to reconsider.

Obamacare has fundamentally and irrevocably changed the relationship between employee and employer. Business owner's are now legally responsible for their employees healthcare. Providing health insurance for employees previously was a business decision. An owner or executive could negotiate or change a contract as required for economic conditions. After Obamacare, such choices are now the province of lawyers and government bureaucrats. This new, obligatory, and unquantifiable expense hangs over all hiring choices, and will influence all efforts to turn the economy around.

Most alarming is how little attention this issue has received from economists, government officials and Presidential candidates. The “employment depression” is portrayed as a macroeconomic issue that can be solved by more stimulus or lower interest rates. In fact, the refusal of companies to take on new employees is a rational response to a government program that failed to consider unintended consequences. Only a politician could be so cynical as to disrupt a basic economic relationship and expect no repercussions.

Obama and Congress have put handcuffs, and maybe an anchor, on the invisible hand of Adam Smith. The weight of Obamacare is pulling down our economy, and it's impact is just beginning to be felt.