Random Thoughts from a Restless Mind

Transparency is the new buzzword in medicine. Systems should be transparent with regard to prices, if not costs. Doctors and other providers of healthcare services should publish their costs and fees, too. Various ratings and measurements have been developed in an attempt to measure that nebulous and elusive entity “Quality”. Calls have been made for transparency here as well; hospitals, doctors, and others are browbeaten to release any and all manner of quality measurements so that we might create something one could call an “informed patient”.

The first, and therefore most important challenge in the quest to measure quality is to agree on a definition of just what quality is. Like all rational discussions the first order of business is to agree on terms and the terms of engagement.

Let’s take the question of evaluating the quality of an individual surgeon. What are the salient metrics? Are we concerned with only outcomes? You know, success rates, complication rates, stuff like that. Is there more to the measurement? Should we be concerned with EFFICIENCY, the ability to obtain high quality outcomes in a more timely manner? How about VALUE, the soft and difficult to measure combination of quality and COST? In this day and age of “economic credentialing” in which doctors, hospitals, and other providers are held responsible for the cost of care, not only on an individual basis but also a societal one, it seems as if value is an inescapable aspect of quality, at least in the eyes of our government and the people who actually pay for healthcare.

Quality measures will be different for surgeons of different stripes; we will want to evaluate different complications and their rate of occurrence for an ophthalmologist versus, say, a cardiothoracic surgeon. Even similar adverse events like infection rates will have a different meaning across specialties. One classic example of a surgical complication is post-op infections. From my limited reading about heart and chest surgery it appears that the post-op infection rate is around 1-2%. This would be scandalous in eye surgery where the post-op infection rate is 100X lower, closer to .01-.02%. Stuff like this should be fairly easy to uncover, or at least you’d like to think so. It turns out that even this metric is rather hard to come by since multiple doctors will participate in the treatment of post-op infections, and literally no one offers up these stats uncompelled. Similar issues apply to specialty-specific complications (vitreous loss, graft leak) for similar reasons.

Right away the difficulty of measuring quality is obvious: even the simple quality measures appear to be something other than simple to discover right now.

Outcome measures are even trickier. Since I know eye surgery best let me stay in that arena and use cataract surgery as my example. For our discussion let’s assume that we have magically been granted unfettered access to every eye surgeon’s charts (and that they are all legible, and that they all contain the same basic information). It should be a rather simple proposition to draft meaningful criteria–let’s say “how well do the patients see after cataract surgery.?”  Would that it were so. The answer to that very simple question–how well do you see after surgery–depends on several variables, and further varies if you ask the question slightly differently. How much improvement did the patient achieve compared with pre-op? How fast did the improvement come? How well does the patient see without eyeglasses?  Is the patient more or less dependent on eyeglasses following surgery? What level of vision constitutes a success? Does the surgeon get the same results with complex cases?

I imagine these issues are not specific to ophthalmology. I can see the same types of questions and complexities in orthopedic surgery, for example. Think about hip replacement–along with cataract surgery and cardiac bypass surgery, hip replacement is arguably one of the most significant medical developments when we think about the quality of life enjoyed by an older person. What defines success in hip replacement? How long do you allow for success to occur for it to be deemed one for the  “win” column? Do we give bonus points for speed in the OR, both from a patient’s standpoint and an economic one? How about a surgeon’s ability to achieve the same level of success in a thin 70 year old tennis player and an obese, cart-riding smoker?

Seriously, if docs can’t come to an agreement about what constitutes “quality”, how can we in good faith measure it? Furthermore, if we WON’T define it we have no one but ourselves to blame when some nameless, faceless 30 year old sociology major in D.C. does it for us.

Nobody asked me (again), but as long as I’m here let me offer up a 3-part proposal to measure and promote quality using surgeons as a theoretical template. Let’s start with a thought exercise borrowed from CrossFit. Fitness training using the CrossFit methodology involves high intensity exercise while trying to maintain near-perfect movement and form. One is shown three targets from a shooting range. The first has random bullet holes all around the bullseye, the second has every shot dead-on perfect, and the third has 95% of the shots within the center bullseye and 5% on-target but not perfect. Which one represents the most desirable CrossFit training strategy?

In CrossFit the answer is “C”, 95% accuracy with the misses still close because this represents the optimal combination of form (accuracy) and intensity (speed). Is this directly applicable to surgery? Well, that depends on how far outside the bullseye the misses land, doesn’t it? And in surgery I think we also need a more accurate measurement of intensity; we need a clock. Speed matters, from both a medical standpoint and a financial one. The shorter a surgery lasts while still hitting the target, the less physically and mentally taxing it is for the patient, and the fewer costly resources (OR time, staff time, doctor time, supplies, etc.)  you are consuming during surgery. All things being equal, the surgeon who achieves the desired outcome faster without increasing her complication rate is the better surgeon.

Put surgeons on the clock.

A successful outcome must be explicitly defined for each common surgical procedure. Pre-operative factors that reduce the likelihood of success should certainly be taken into account (e.g. a morbidly obese cart-riding smoker and hip replacement), but care needs to be taken so that a measurement can’t be gamed (two guttata do not constitute a corneal dystrophy and increased likelihood of swelling) in order to work with a lower standard. Surgical societies should show some spine and make a call, define what constitutes a high-quality outcome, regardless of the howling that will emanate from the mediocre and the incompetent. It’s gonna happen anyway, and physicians making the call would be orders of magnitude better than MBA’s and philosophy majors.

Lastly, quality should be measured, publicized and praised, and those surgeons (and other doctors) should be explicitly rewarded with as many cases as they can (or wish to) handle. They should also be paid more. Once we decide what constitutes quality we can measure it and publish the data. People will understand this, just like they understand the data in a box score. Why is it so OK for the baseball player with the highest batting average or lowest ERA to be paid more based on his success, yet somehow the most efficient surgeon who has the best outcomes is labeled a “money grubber” who must somehow be doing something wrong if he is also very busy? We want that high batting average guy at the plate in the 9th inning of a tight ballgame, and we pay him more because of his higher quality outcomes. Why aren’t we doing the same thing with surgeons? The very least we can do is stop accusing surgeons of being successful!

It’s time that we apply basic theories about quality to medicine in general and surgery in particular. Indeed, it should be easier to do it with surgeons. Make a call–define a successful outcome. Pull out a stopwatch. Faster, more efficient surgery is less expensive and generally less taxing physically for patients. Once the data is available be transparent and publish the results. I know what Miguel Cabrera is batting this year; my patients (and potential patients) should know my “batting average” in the OR. While I hold out little hope of being heard on this last point, uncountable articles support the benefit of the carrot at the expense of the stick when it comes to promoting excellence. Higher quality should beget higher pay. At the very least we should stop with the assumption that the busy surgeon is somehow “getting over”, guilty of somehow gaming the system (eg. doing unnecessary surgery) until and unless proven innocent.

She may just be better.

The onus for reducing healthcare costs has been placed squarely in the middle of the backs of physicians. At the same time, physicians are being graded on how well they “satisfy” their patients. Rock, meet Hard Place. Hard Place, Rock.

Two recently published studies referenced pretty much everywhere have shown that individual patients specifically do NOT want to take cost into consideration when it comes to making decisions about their own care. In addition they also do not want their physicians to give any consideration to cost concerns when diagnosing or treating their own illness. Indeed, when given the choice between two treatments of nearly equal efficacy, study subjects overwhelmingly chose the more expensive option for themselves even when the difference in efficacy was very small.

While the authors of the articles citing these studies were shocked at these findings, the only surprise in my mind is that anyone is the least bit surprised by any of this.Think about it. You will personally pay little to none of the difference in cost of the treatment out of your own pocket for a treatment or a test that someone has labeled “better” or “more effective”. You’re telling me you’re not gonna choose that one? Please.

The two great forces aligned against one another in the “Healthcare Reform” debate advocate respectively: market-based incentives in which a patient is given better information in return for shouldering more of the financial decision-making and the importance of the quality of the exerience, and top-down command and control strategies in which both carrots and sticks are applied to doctors in an attempt to get them to provide better care with a more friendly consumer experience while at the same time spending less money. Physicians must provide more and better for less, and must do so under the same zero-sum malpractice game of “GOTCHA” rules we have now.

All of the responsibility for lowered costs with better outcomes and a better quality experience for the patients is shouldered by docs in Obamacare. Accountable Care Organizations (ACO) are lauded for paying physicians a set salary rather than by work done. Unless, that is, you do less work, quality notwithstanding. Getting great outcomes, following best practices, and receiving high satisfaction marks get you a pay cut if you see fewer patients, generate lower test fees, or do less surgery. The Rock.

Play by the rules, see your prescribed load of patients, get great outcomes and practice to the letter of evidence-based medicine, but fail to get those high customer satisfaction marks? Ah…welcome to the Hard Place. Your pay depends on satisfying your patients. Meeting their expectations both for their experience as well as their care. You know, those same patients who only care about the cost of someone else’s healthcare, not theirs. Fail to order the test that rules out the 0.00001% chance of that rare tumor on Anderson Cooper Live last night? BZZZZZT. Bad doctor. 1 out of 10 on the patient satisfaction survey and a trip to the principal’s office to learn about your pay cut.

Man. It wasn’t enough to be in the crosshairs of every plaintiff’s lawyer under the sun (so Doctor, isn’t it possible that you might have saved this patients vision if you’d ordered that MRI to evaluate her headache?). Nope, now we are responsible for balancing the Federal budget while simultaneously giving every patient whatever care they’ve seen on Dr. Oz (“PET Scans–your doctor KNOWS you need one if you have a headache! You could go BLIND!!”). It’s a lot to ask of your doctor.

Unless, of course, it’s someone ELSE’S headache.

CrossFitters have taken up the cause of health, given the charge of improving health and preventing decrepitude. There will always be a need for what we can call “real medical care” or sickcare (you know, rather than healthcare). After all, stuff happens. I’ve been plunged into the abyss of American sickcare as I help shepherd my Dad through a prolonged exposure.

Much has been made of the tremendous costs of the most modern medical care. There was a 20 page article (20 pages!!) in Time magazine about this last week, about inflated charges and financial gamesmanship and whatnot. True enough. Indeed, I’ve read the theory that sickcare in the U.S. was pretty darned good 10, 20, 30 years ago, and we spent much less money for it back then. Why not just use, say, 1980′s sickcare as our standard? Weren’t we pretty healthy then? It sure seemed like we could at least afford sickcare then, both on the personal and societal levels.

Here’s the rub: I saw 2013 vintage care this week, and I saw something that approximated 1985 or so. The “time travel” between 1985 and 2013 was a real eye opener. No one in their right mind would trade the best of what we have today for “1985 is good enough”. Trust me. That particular “time travel” trip was a nightmare.

Do we as a society, country, and/or economic ecosystem need to find some way to bring some sanity, some rational economics to how we buy and pay for our “sick care”? You bet. We here in the CrossFit world are on the right track as we seek health, seek to avoid the need for sickcare. But man, I gotta tell ya, if you are sick and you need to be cured, you want to be right here in North America.

And you want to be be here today, in 2013.

While driving to work this morning I had NPR on the radio as usual. The Business News segment was featuring the Panera Bread company and its “Panera Bread Cares” program. Briefly, Panera has converted about a dozen of its formerly for-profit stores into non-profits owned by the Panera Foundation. There are no prices in these stores, only “suggested donations.” Approximately 20% of patrons donate more than the suggested amount, 60% pay as if it is regular price, and the rest pay little or nothing.

Needless to say, the folks from Panera were more than a little self-congratulatory about this enterprise, and I think they have some reason to be so. Their stated goal is to raise awareness of “middle-class food anxiety”, not so much to provide food to the poor or the homeless. I imagine that the paying customers might be a little less prone to continue patronizing a store which all of a sudden started to be populated by the various and sundry homeless, especially those who look the part. Still, I do think this is an interesting experiment along the lines of Radiohead and music but for charity rather than as a business model.

Here’s the rub: a Professor Somebody from someplace opined that it is “exceedingly rare” that a business has a charitable venture that is indistinguishable from its for-profit core business. I wish I remembered the guys name. He intimated that it might actually be unique, not seen in any other business. Right. About that. This is the self-congratulatory part that rankles. Unique, as in only one, like never before seen?

Hardly.

How about the countless private doctors’ offices and clinics that have been seeing and treating patients for little or no payment, a phenomenon that began decades ago and continues today? Have we become so jaded about doctors and healthcare that an economics or business professor can state, presumably with a straight face, that a company offering to give away its core product in its usual setting is unique and almost unprecedented?

Come on now.

I’m reminded of a story one of my older partners used to tell. Dr. Scheie, namesake of the Scheie Eye Institute at Penn in Philadelphia, was a pioneer in cataract surgery. Every one of his patients had the same experience in the operating room itself, and Dr. Scheie personally did every single surgery; no one was denied surgery by the great Scheie, regardless of their ability to pay. Where they spent the next several nights (this was in the days of sand bags and immobilization) was determined by what, if anything, they did pay. Regular patients, those who paid the “recommended donation”, were the majority of the patients and they stayed in semi-private or double rooms. Those less well off who paid little or nothing were tended to in a dormitory like ward. There were two private rooms reserved for those who were of more substantial means. When asked what surgery would cost if one were to spend the night in a private room Dr. Scheie would reply: “you should pay what you feel you should.” The eye clinic never lost money.

I think the idea and philosophy behind the “Panera Bread Cares” is pretty cool, but let’s be real about both the phenomenon and the real rationale underlying these “pay what you can/want” stores. Panera is getting enormous publicity and goodwill from a trivial number of store conversions. It is getting great feedback and outsized credit for something that is so common in medicine that business professors seemingly forget that and get on NPR and say stuff like Panera Bread Cares is so rare that it might be a one-off. They are giving away bread bowls, for Heaven’s sake.

Doctors have been giving away something much more valuable to those who can’t pay every day for decades.

The great Dick Lindstrom recently posted an editorial on the challenges faced by doctors in a world that is focused solely on the cost of medication, one in which pressure is brought to bear on both doctor and patient to use an inexpensive generic at all times. Dr. Lindstrom reaffirms his career-long position that only one factor matters in the complex decision making process that is medicine: what is best for my patient’s health is my sole concern. Indeed, it is important for each physician to fight for this outcome, to fight for the person who sits before us in the exam chair or beneath us on the operating table. When a clinical difference exists between the expensive branded medicine and the cheaper generic we are honor and duty bound to prescribe and support the better medicine.

Sigh. It’s just all so tiresome, this battle. We physicians certainly did not choose this fight, and frankly most of us have no dog in the fight other than the best interests of our patients. I wrote PREVIOUSLY that the notion that pens, penlights, and candlelight dinners prompt doctors to become shills for pharmaceutical companies is farcical and offensive. Come on…I’m gonna look for a reason to prescribe some new eyedrop because someone dropped off a couple of pens? That’s all silly enough, but the battle has escalated with the entry of insurance company and government programs that automatically switch to a less expensive “therapeutically equivalent” medication and then require doctors to personally run the gauntlet necessary to “justify” their clinical decisions.

We are on the receiving end of the same kind of stuff that big companies use to defeat smaller foes in court: we are bombed with paperwork. Not only that but it’s carpet bombing, indiscriminate deluges of time bombs meant to bludgeon doctors into submission. There’s collateral damage, just like in carpet bombing, only the casualties are more subtle. Forcing doctors to be a part of this irreparably damages the doctor-patient relationship, making it more of a commercial interaction as doctor becomes ombudsman for patient.

As Dr. Lindstrom exhorts, I’ve been fighting the good fight. Dr. Lindstrom doesn’t need this fight. He’s a living legend who has earned the right to stand aside from these types of petty issues and to choose to put his considerable gravitas to work on stuff that has to be more fun. Yet he willingly takes on this battle and I’ve followed his lead. Standing my ground and insisting on newer branded meds when they are superior to older, cheaper generics. It’s getting to me, though. I’m tired. My staff is tired.

I surrender. Up goes another white flag.

I’m going to surrender in the battlefield of Glaucoma. Why Glaucoma and not cataract surgery for instance? I’m tired and beaten up, but I’m neither a hero nor a coward, not a sentient nor an idiot;  I don’t need to be a seer, some kind of morbid Karnac the OK, to know the outcome for either cataract or Glaucoma. I’m declaring right up front what is going to happen, how it will affect my patients, my staff, and me, and what the ramifications will be for American healthcare. I’m surrendering in Glaucoma because I can, continuing to fight in cataract surgery because I must.

In my 27 years as a physician only one paperwork/government regulation/billing issue has ever resulted in better care of my patients: the requirement to do an extended Review of Systems for a particular kind of visit resulted in the identification of major side effects from glaucoma eyedrops. Indeed, this was a total surprise and led to a rapid change in the way we took care of Glaucoma patients. Older medications, effective or not, were replaced by newer medications or laser because the newer treatments were both more effective and freer of side effects. What will I find this time?

Timoptic (topical Timolol) was introduced in the early 1980’s. It was a Godsend. Nothing less than a miraculous savior of vision, keeping legions of patients out of the operating room and saving thousands and thousands of people from certain blindness. It’s been off patent for decades but is now no more than a third line treatment. Why? Tons of side effects, some subtle (decreased exercise capacity, erectile dysfunction) and others less so (my friend essentially killed his very first Gaucoma patient in year one of the Timoptic era by prescribing Timoptic and causing 1st degree heart block). It’s really cheap now, but who can write this Rx and look themselves in the mirror, white flag or not?

We know that the Lipid class of Glaucoma eye drops is the most effective group of pressure lowering medications. The original, Xalatan, dethroned Timoptic in less than 2 years. Lower eye pressure and no systemic side effects and a new treatment paradigm was nigh. The worst side effect was a permanent darkening of the iris in 9% of patients, the price to pay to save your vision. Xalatan is now available as a generic (latanaprost). There are 3 newer, stronger, more effective Lipid medications, all of which are branded and all of which are 2-4X the cost of latanaprost. They all reduce eye pressure on average 2-3 points more than latanaprost.

I’ll start here. Starting next week every new glaucoma patient who opts for medical treatment will start on latanaprost. On top of that I will change every patient on a branded lipid to latanaprost if they risk losing insurance coverage for their drop. I will not respond to any insurance company challenge. If pressure reduction is inadequate I will follow my standard protocol and I will offer a second medication or glaucoma laser treatment, both of which are standard of care. If a second medication is chosen I will write for the generic second line Rx, an alpha-agonist. The generic and the brand alpha-agonist have equal efficacy; the generic has a 35-40% unacceptable side effect rate compared with the brand’s 10-12%. The generic cost is ~1/4 of the brand.

My staff and I will take the time necessary to inform my patients of these side effect issues, a time investment that will be a laughably small fraction of the time it takes us to fight the paperwork wars for Brand coverage. I will document this up the wazoo, noting every treatment failure and every last little side effect, jotting down every incidence of patient non-adherence. I will gear up for more glaucoma surgery, both laser and incisional, because I remember how much more of both I did in the days when Timoptic was king, in the days when version 1.0 of today’s medicines was so hard to take due to side effects. I will have this all on hand when we start to read of the new golden age of Glaucoma surgery.

I will be ready to answer the critics who accuse eye doctors of doing too much Glaucoma surgery.

I have been pretty generous in sharing my thoughts about some of the ills of our American Healthcare system, especially with regard to the barriers erected between physicians and patients. The attempt to “reform” medical care via a top-down, bureaucratic solution to what may or may not ail our system is ridiculous on its face. We are to believe that our Federal Government can handle something as complex as healthcare, a segment of the economy representing ~20% of GDP? A Federal government that has proven so adept at managing other major segments of our economy like, oh, energy policy?

The “baby with the bathwater” approach in the halls of our Capitol and the editorial offices of our leading media outlets (WSJ excepted) is about as wrong-headed as you can get.  What we need is an AMERICAN solution to the challenges that we presently face with the economics of healthcare in the U.S., using our present system as the foundation. We need a solution that emphasizes the strengths of our markets, with government providing oversight to establish a playing field that is as level as possible.

Not surprisingly, I have some thoughts!

1) Malpractice tort reform. See my thoughts in “Tort Reform = Healthcare Reform”. Effective reform will dramatically reduce the scourge of defensive medicine with its attendant costs and risks to patients. We all do it, and we do it when we don’t get paid to do it. Defensive medicine represents 15-25% of all medical costs in the U.S. That’s 15-25% of $2.5 Trillion. Do the math.

2) Tax Reform #1: Remove the tax deduction for employer-offered health insurance. Provide a 100% TAX CREDIT to the lowest 60% of wage earners for the purchase of health insurance. Provide a progressive TAX DEDUCTION for the upper 40% of wage earners. Level the playing field by removing the penalty for not working for a company that can deduct your insurance premiums.

Tax Reform #2: Remove the tax deduction for advertising as a business expense for Hospitals. If we are concerned about unnecessary increased utilization of medical resources why are we allowing advertising by hospitals? Seriously, why are we subsidizing the Ohio State Medical Center when it advertises for business in Cleveland. Ohio State is in Columbus, 2.5 hours away.

For that matter, remove the tax-exempt status of any hospital or  provider that advertises. How is it appropriate to allow a hospital system to advertise to increase revenue, deduct that advertising as an expense, and still be not-for-profit? If it looks like a business, acts like a business, and sounds like a business, tax it like a business.

3) Insurance Reform #1: Reverse all of the for-profit conversions of previously not-for-profit health insurance companies. Who was the genius who thought THIS was a good idea? I don’t remember insurance premium increases that were quite so massive when all of the Blue Cross/Blue Shield plans were not-for-profit, do you? And while there were $Million execs in the non-profits I don’t recall any $10, $20, or $100 Million execs. Removing the need to answer to the stock market will create companies that will compete quite nicely with the for-profit companies without the horror of a government run system. Let the equivalent of NGO’s compete with the United Healthcares of the world.

Insurance Reform #2: Remove state-level coverage mandates and create a minimum federal set of mandates for comprehensive insurance policies. A REAL minimum. REAL medically necessary items. This is the brilliance of Sweden’s system. No Viagra or artificial  insemination coverage. Allow cross-state competition for the business. Real competition always drives prices lower.

Insurance Reform #3: Do whatever it takes to encourage the purchase of  high-deductible catastrophic health insurance for all. Real insurance that covers real medical disasters like car accidents or cancers that strike young adults.

Insurance Reform #4: Allow insurance companies (Medicare and Medicaid included) to discriminate IN FAVOR OF people who make healthy lifestyle choices (eg. no nicotine, no DUI, etc.). We are all so afraid of the stick that we refuse to allow any use of the Carrot.

4) Freedom of Speech/Restraint of Trade Reform #1: Abolish, once again, direct-to-consumer pharmaceutical advertising. There was a quantum leap in the utilization of all sorts of medications immediately following the 1997 rulings that allowed DTC pharmaceutical marketing. If it is so obvious that our ever-increasing levels of spending on medical care is a threat to the very existence of our fair Union, then DTC drug marketing is a version of yelling “FIRE” in a crowded theater.

Freedom of Speech/Restraint of Trade Reform #2: Begin a return to the professionalism of yesterday by prohibiting all forms of advertising by, or for, physicians. The AMA gets a lot of criticism, most of it well-deserved in my opinion, but the court and FTC rulings that prohibited the AMA from censoring physicians who advertised was a seminal event in the de-professionalism of doctoring and medicine. Doctors and other medical advertising was, is, and always will be wrong. While we’re at it, do the same thing for lawyers and the practice of law.

5) Public Health. Finally, and most importantly, go to the true root of whatever “Crisis” we may have here in the United States, be it a “Healthcare Crisis” or a “Healthcare Finance Crisis” or what have you. We as a people are not healthy; certainly not as healthy as we ought to be. We are not healthy because of some wrong-headed previous Public Health decisions (simple-carbohydrate based diets, abolition of school phys-ed programs, tort-fearing closures of playgrounds, etc.). We are not healthy because our ability to treat the diseases that result  from poor lifestyle choices (cigarette smoking, alcohol abuse, preventable accidents, etc.) is SO GOOD that we are able to keep more and  more unhealthy people alive longer and longer, paying ever more to do so along the way.

This is where true leadership can make a difference. Remember JFK and the President’s Council on Fitness? I do. 8 pull-ups in the fifth grade for me. Sweden identified saturated fats from whole-milk products as a significant cause of heart diesease in the 70′s; a full court Public Health press for low-fat dairy brought about a dramatic decrease in cardiac deaths in the 80′s. Polio, measles, smallpox and whooping cough were once the leading killers of children in the U.S. but are now historical footnotes due to Public Health initiatives.

We lead the world in per capita alcohol related accidents and deaths, losing young lives by the thousands each year (is it just me or does it seem we have MORE alcohol-related problems in our youth since raising the drinking age?) We have ever more increasing numbers of truly obese citizens who go on to suffer the diseases caused by that obesity, and we pay ever more for their diabetes, hypertension, strokes and heart attacks. These lifestyle choices are root causes for our increased expenditures on Healthcare, much more so than all of the targets of Beltway demagoguery like insurance company expense ratios and pharmaceutical company profit margins. A solution to this issue, more than all of numbers 1 through 4 combined or any other proposal yet floated, is the true crux of the solution to any “Crisis” we may be facing. Everything else is only there to buy time. Time to get healthy.

It’s a Presidential Election year in the United States. There are no votes to be had in making Americans healthier. Nothing but hard work on every side of the equation. Who will stand up and do the hard work? Who will lead?

Who will have the guts to not only say that the Emperor is naked,  but also drunk and fat and puffing away our economy.

I have been pretty generous in sharing my thoughts about some of the ills of our American Healthcare system, especially with regard to the barriers erected between physicians and patients. I find the various proposals now before our legislative bodies in Washington to be rather curious, even offensive. Since when does the United States of America adopt wholesale an economic solution from another country? Especially another country that is in some way otherwise riding the considerable coattails of the U.S. economy?

The “baby with the bathwater” approach in the halls of our Capitol and the editorial offices of our leading media outlets (WSJ excepted) is about as wrong-headed as you can get.  What we need is an AMERICAN solution to the challenges that we presently face with the economics of healthcare in the U.S., using our present system as the foundation.

Not surprisingly, I have some thoughts!

1) Malpractice tort reform. See my thoughts in “Tort Reform = Healthcare Reform”. Effective reform will dramatically reduce the scourge of defensive medicine with its attendant costs and risks to patients. Defensive medicine represents 15-25% of all medical costs in the U.S. That’s 15-25% of $2.5 Trillion. Do the math. While we’re at it, how is it good for the country to allow the tort bar to advertise for cases? Rake the muck in the hopes of unearthing errors or imagined?

2) Tax Reform #1: Remove the tax deduction for employer-offered health insurance. Provide a 100% TAX CREDIT to the lowest 60% of wage earners for the purchase of health insurance. Provide a progressive TAX DEDUCTION for the upper 40% of wage earners.

Tax Reform #2: Remove the tax deduction for advertising as a business expense for Hospitals. If we are concerned about unnecessary increased utilization of medical resources why are we allowing advertising by hospitals? For that matter, remove the tax-exempt status of any hospital or  provider that advertises. How is it appropriate to allow a hospital system to advertise to increase revenue, deduct that advertising as an expense, and still be not-for-profit? If it looks like a for-profit business, acts like a for-profit business, and sounds like a for-profit business, tax it like a for-profit business.

3) Insurance Reform #1: Reverse all of the for-profit conversions of previously not-for-profit health insurance companies. Who was the genius who thought THIS was a good idea? I don’t remember insurance premium increase that were quite so massive when all of the Blue Cross/Blue Shield plans were not-for-profit, do you? And while there were $Million execs in the non-profits I don’t recall any $10, $20, or $100 Million execs. Removing the need to answer to the stock market will create companies that will compete quite nicely with the for-profit companies without the horror of a government run system. Let the equivalent of NGO’s compete with the United Healthcares of the world.

Insurance Reform #2: Remove state-level coverage mandates and create a minimum federal set of mandates for comprehensive insurance policies. A REAL minimum. REAL medically necessary items. No Viagra or artificial  insemination coverage. Allow cross-state competition for the business. Real competition always drives prices lower.

Insurance Reform #3: Allow insurance companies (Medicare and Medicaid included) to discriminate IN FAVOR OF people who make healthy lifestyle choices (eg. no nicotine, no DUI, etc.). We are all so afraid of the stick that we refuse to allow any use of the Carrot.

4) Freedom of Speech/Restraint of Trade Reform #1: Abolish, once again, direct-to-consumer pharmaceutical advertising. There was a quantum leap in the utilization of all sorts of medications immediately following the 1997 rulings that allowed DTC pharmaceutical marketing. If it is so obvious that our ever-increasing levels of spending on medical care is a threat to the very existence of our fair Union, then DTC drug marketing is a version of yelling “FIRE” in a crowded theater.

Freedom of Speech/Restraint of Trade Reform #2: Begin a return to the professionalism of yesterday by prohibiting all forms of advertising by, or for, physicians. The AMA gets a lot of criticism, most of it well-deserved in my opinion, but the court and FTC rulings that prohibited the AMA from censoring physicians who advertised was a seminal event in the de-professionalism of doctoring and medicine. Doctors and other medical advertising was, is, and always will be wrong. While we’re at it, do the same thing for the rest of the lawyers and the practice of law.

5) Public Health. Finally, and most importantly, go to the true root of whatever “Crisis” we may have here in the United States, be it a “Healthcare Crisis” or a “Healthcare Finance Crisis” or what have you. We as a people are not healthy; certainly not as healthy as we ought to be. We are not healthy because of some wrong-headed previous Public Health decisions (simple-carbohydrate based diets, abolition of school phys-ed programs, tort-fearing closures of playgrounds, etc.). We are not healthy because our ability to treat the diseases that result  from poor lifestyle choices (cigarette smoking, alcohol abuse, preventable accidents, etc.) is SO GOOD that we are able to keep more and  more unhealthy people alive longer and longer, paying ever more to do so along the way.

This is where true leadership can make a difference. Remember JFK and the President’s Council on Fitness? I do. 8 pull-ups in the fifth grade for me. Polio, measles, smallpox and whooping cough were once the leading killers of children in the U.S. but are now historical footnotes due to Public Health initiatives. (A pox on all the cretins advocating against childhood immunization).

We lead the world in per capita alcohol related accidents and deaths, losing young lives by the thousands each year. We have ever more increasing numbers of truly obese citizens who go on to suffer the diseases caused by that obesity, and we pay ever more for their diabetes, hypertension, strokes and heart attacks. These lifestyle choices are root causes for our increased expenditures on Healthcare, much more so than all of the targets of Beltway demagoguery like insurance company expense ratios and pharmaceutical company profit margins. A solution to this issue, more than all of numbers 1 through 4 combined or any other proposal yet floated, is the true crux of the solution to any “Crisis” we may be facing. Everything else is only there to buy time. Time to get healthy.

Pick a number; choose an age. 40. 50. 60. Anyone under that age gets “Well-care” or “Get Healthy Care” starting right now. Over that age they can have “sick care” only if they wish, but under that age if you try to be healthy you get rewarded.

There are no votes to be had in making Americans healthier. Nothing but hard work on every side of the equation. Who will stand up and do the hard work? Who will lead?

Who will have the guts to not only say that the Emperor is naked,  but also drunk and fat and puffing away our economy.

Sunday musings (courting controversy)…

1) Volume. If you undertrain you may not finish; if you overtrain you may not start.

Lotta meat on that bone, especially around Games season.

2) Enabler. One who provides either implicit or explicit support of dysfunctional or harmful behavior.

I am an American physician, a specialist. Universally reviled, and nearly universally acknowledged as being at the root cause of what people regularly call our “dysfunctional healthcare system.” Funny thing, though, but my specialty includes providing ongoing care to patients with chronic eye diseases. I actually bridge the divide between specialty care (highly complex, single–organ surgery) and chronic primary care. Every day in my office I see patients with type II diabetes and other diseases that are at the very least highly influenced by lifestyle decisions.

We do not really have a healthcare system in United States, but rather a sick–care system. We actually do a pretty good job in pediatrics with a well thought out, well–established system of well–baby and well–care visits for the vast majority of children in America. Somewhere after our children leave their pediatricians in their teens the whole concept of well–care seems to disappear. No longer guided by the doctors of their youth, Americans are left to their own to make decisions about where their priorities will lie. This is certainly true of health and wellness.

There is an article on CNN.com today written by a very well spoken, highly intelligent and intuitive primary care physician from New England in which he cites a couple of examples of patients who got sicker when they decided they could not afford care for their illnesses. His approach disappoints me greatly; the appeal to the emotional is just one more way that our American sick–care system is the great enabler of our Nation’s un-well.

Think about it. We actually have the very best sick–care system on the planet. We manage to keep incredibly sickly and unwell Americans alive, and to some degree functional, in SPITE of horrific and horrible health–related decisions on the part of these individuals. Cardiac bypass surgeries and coronary artery stents. Evermore complex oral diabetic medications layered one upon the other. Heroic, simply brilliant surgical interventions to replace the joints of people who managed to double and triple the “load” they were meant to carry.

Our “health care system” not only enables our population to abuse their health and their fitness by rescuing them from their excesses, but in its present and proposed future forms it also insulates them from the responsibility of being healthy. There are certainly a minority of people who cannot afford sick care, but that number is buried by the number of people who choose to not be able to afford either health-maintenance or sick care. You only need to spend one day in a doctor’s office watching people finish a conversation on their iPhone ($499 + $100/month) about a game they watched on ESPN last night ($80/month for cable) before heading to the brewpub (smothered fries!), as they walk out to their new car ($500/month) to retrieve their iPad ($699 + $60/month) and catch a quick smoke ($5/pack, 1 pack/day), just before they complain to their physician about how hard it is to pay for their diabetes medicine.

3) DWB. Driving While Black. No matter what the story eventually turns out to be, there is very little that is good that is likely to come out of the Trayvon Martin debacle. Not for the Martin family, not for that neighborhood watch guy, and probably not for society as a whole, at least for quite a while. Why? For the simple reason that it is now 2012, we’re still having this conversation, and nobody has demanded change.

Let’s go back a bit, shall we? How about a trip to 1979 and suburban Rhode Island. I’m driving the family beater, my close friend in the passenger seat waves at a police car as we drive by on our way to the mall. My close friend, STILL my close friend, happens to be a very large Black man. You guessed it–flashing lights followed by “license and registration (no please).” Why? A version of Driving While Black.

“Come on, bingo. That’s ancient history. Things are different now.” Well, let’s move forward a bit. Dinner chez bingo sometime around the year 2000. My good friend the Rev. Mel and his beautiful wife are joining us at our house for dinner. Mel, a black Baptist minister, drives a bullet-proof Mercedes sedan. Never more than 5 mph over the speed limit. The Woodards were late for dinner. When I teased him about it Mel just shrugged his shoulders and said “DWB.” Even impeccably dressed for a dinner out, Mel was still a Black American man.

Now? I young black man in a hoodie returns from an errand, surely guilty of something until proven innocent. A non-black man approaches the youth, surely someone to be feared until proven otherwise. The fault, my friends, lies on BOTH sides of the conversation. At this late date in history it no longer matters what came first, you know? One side of the conversation needs to openly acknowledge that the vast majority of the other side does NOT participate in violent criminal activity. This part of the community needs to openly acknowledge this and aggressively teach that lesson to people of all ages. The other side of the conversation needs to openly knowledge that their ARE small parts of their community who DO engage in violent crime and to go about the hard work of isolating them as the outliers that they are and shunning them as a pox on BOTH communities.

We need to be done with the blame game. Indeed, indulging in finger-pointing at this late historical stage is also a type of enabling. By taking the easy way out, blaming this one for not fighting harder against unsupportable prejudice or pointing the finger at that one for some weak justification for criminal behavior is quite simply enabling the prejudiced and the predators to continue their pathologic behavior patterns.

NONE of us could have influenced the tragic outcome of that encounter In a random Florida neighborhood. ALL of us…Black, White, and other…have the duty and the responsibility and the ability to do the hard work necessary to prevent what STARTED it.

Start now.

I’ll see you next week…

Comment #16 – Posted by: bingo at March 25, 2012 8:38 AM

One of the strongest statements yet made in support of the private practice of medicine was made this morning at 8:00 AM, EST. I went to work.

What’s the big deal? Of course you went to work. You’ve got a job and today is a work day. Ah, Grasshopper, there’s the rub. I am a doctor in private practice. I don’t have a job, I own a job. I don’t report to any centralized HR department; there’s no single supervisor looking over my shoulder. Nope, I’m a practicing physician in a private practice specializing in eye care, and this morning there are some 60 patients who’ve scheduled appointments and a staff of 14 on their way in to the office, all of whom are depending on me going in. So even though I feel like a damp campfire long past its useful life, I came to work.

If all I had was a job I’d a stayed in bed.

The dirty little secret of private practice medicine is that market-based economics works on a micro basis. There’s payroll to meet and rent to pay. The mere perception that your patients will leave your practice if you don’t go to work drives the private practitioner to work even when she feels lousy. Even more than that, the absence of a corporate barrier between doctor and patient makes the private practice doc think twice before he takes that sick day, because each one of those patients belongs to him, and vice versa. The unfiltered connection is so personal that the private practice doc thinks about what Mrs. Pistolaclionne (bonus points if you name the movie) will say if he calls off sick.

The dirty little secret in large, corporate medical practices is that market-based economics work there, too. All that talk about how your “World Class Clinic” doctor isn’t paid by how much work he does? Nonsense. In fact, the amount of money generated by any individual doctor is even MORE closely monitored and includes stuff like how many tests and procedures get done on her patients even if she isn’t doing the work herself. That doc’s compensation is absolutely driven by how much revenue she is responsible for bringing into the institution.

It’s just that the corporate Doc doesn’t own a job, he simply has a job. He has no direct responsibility for the staff surrounding him or the bricks and mortar over his head. His compensation is driven by his corporate performance, and that compensation includes time off for vacation and for sickness. Leaving time on the table is the same as leaving money there. There’s no bonus for loyalty to the institution. Points aren’t accrued for attendance. Frankly there are no real points to be won for extraordinary customer satisfaction, only demerits for egregious behavior. Unused time off, like extending your hours or taking patient calls when it’s not your turn, is simply donating your services and talents to your primary constituent, your boss the institution.

We should all be very cautious about the trend toward fewer private practice doctors and more docs employed by ever-larger institutions. Continuity of care is more than simply an always available electronic chart, it’s also a relationship forged over time between two real, live people with skin in the game. The next time you see your private practice doc and she’s a little sniffly and hoarse, remember to give her a little pat on the back and a ‘thank you’. After all, she owns this job and could have stayed home today, but she knew you had an appointment.

She knows who she works for!