Tuesday, September 30, 2008

Health Train Express Fuel

Quote of the day:
The real problem is not whether machines think but whether men do. - B. F. Skinner


Most locomotives run on diesel fuel or electricity. In fact even the diesel engines use electricity to drive the wheels by converting the diesel energy with electric generators that drive the electric motors.

In the case of our health train the fuel is not diesel, but beans,

and not only one kind of bean, but many kinds:

small red beans


Five kinds of beans

  Actor Bean

Jelly Beans

and instead of having a fuel gauge

we have an endless number of bean counters.

Now we all know that beans produce an extraordinary amount of flatulence

and methane...  This contributes greatly to global warming.  ....


And this brings  us to the topic of  "waste" note you made need to sign in to read this document from Price Waterhouse Cooper.

Saturday, September 27, 2008

Who Killed Healthcare?

Healthcare in America is not dead.  It is critically ill...it will not die, because it is the basic stuff of life....not to be denied. Darwinians know that the strongest survive....both as individuals and as a species.


No one is writing 'DNR' in the chart nor on the forehead of our unconcious,  but not  quite vegetative patient.

Maybe we all can resurrect our patient with miracles, and teamwork.....A medical home for healthcare, and not just for patients. What do you think it would take.....I've been doing it for 40 years, and don't pretend to know an answer....Most of my colleagues have been doing it a long time as well....ask them and you will receive a litany of answers.....Most have been too busy surviving their patient load,

trying to run their business, and hopefully having some time for families. On the surface we all seem composed, imperturbable, and equanimous, however under the surface all the frustration

and anger, managed hundreds of times a week take a toll.  There are few patient encounters that do not stumble into some bureaucratic or regulatory mechanism. Many physicians have divorced, lost their family and have become alienated from normal society.  Many know no other way of life.

Race horses are bred and raised to race

.....that is what medicine is like...a race from the time you enter college or medical school.

Race for grades, race for internship and post graduate training, race to set up a practice, race to keep current, race to keep up with paradigm shifts, avoiding lawsuits, somewhere along the line the younger race horses catch up and pass you...You are put out to pasture, find an administrative position, or worse,like the race horse in the pasture dwindle and die.

  Some of us begin writing, and also attempt to mentor or nurture young colleagues, not so much in medical wisdom, but the sort of wisdom from an older colleague who has been through it all.

  I like to compare this to McCain vs. Obama.   Things like how to judge character, how to have integrity, and not follow the crowd. How to say NO!  The older warrior who can dip from experience, both successful and more important, failures.

Young achieving professionals are bent on proving how right they are, fearing a failure will mark them as unsuccessful.  Old warriors have lived and done it....are not preoccupied with demonstrating how right they have been, nor fearful of demonstrating their lack of failure.

A big change that I noticed about ten years ago is that despite my own relative youthful attitude I could not advise younger physicians because my world in medicine was so different. I needed to dip into their lives, professionally to see how they related to the new system.  I could attempt to advise them on being a good and moral person, to set priorities, and what success really means.  Often when I spoke to residents as I pontificated, their eyes would glaze over....like most young people...they would wonder what I was talking about.

Americans have never failed to overcome crises, it is the best part of us.....not our government ,but our people. 

Friday, September 26, 2008

Health Train Express reaches the end of the Tracks

Quote of the day:

The best way to predict the future is to invent it. - Alan Kay


Today several health blogs are beginning to write about what is happening to the American and perhaps World Economy.

We have been looking inward in healthcare, and most surgeons, and physicians are so busy with patients they at times don't even want to know what is going on in the world about them.  This is more than foolishness from a group of people who are far and away more intelligent than most others. ( I don't equate being smart with high intelligence).  Physicians need to be strong leaders not only in health care but in matters affecting finance, public policy, community health, education, and social welfare.  Physician leaders in the past were always at the center of their communities, on school boards, in advisory capacities to city and county and state councils.  We are not in control...nor should we be, but we certainly can influence and exert leverage on those who do make these decisions.

In todays Covert Rationing Blog ,Dr Rich elaborates:

"That tipping point, it appears, came last week.  And so, the American taxpayers, many of whom take great pains to live within their means and don’t borrow money they cannot pay back, are the only ones left to rescue the greedy and the stupid and the craven.


Assuming our economy does not actually collapse

over the next few months, and thus does not wipe out our entire social contract (to the extent that we will have to start all over, and thus render moot any concerns over any future fiscal crises our current social contract promises to bring us), DrRich would like to point out that, compared to what is coming, the economic crisis we are now experiencing is merely a trifle."

I think this is very well stated..

The only reason congress might announce a solution to the imminent collapse would be to placate and avoid a financial panic.

Tonight will be an indicator of the future. If congress 'passes' a bailout plan it will be no assurance it will happen as announced.

If it does not announce a plan, a rapid freeze of the financial system could become apparent over the weekend. WAMU  was the second largest commercial bank, and FDIC could not afford to insure their deposits without itself being imperiled; fortunately they found a private buyer. The system is more than stressed.

Whereas the newly-burst mortgage bubble has left us with an unfunded liability of merely (we think) something less than $2 trillion, our unfunded liability for Medicare alone, over the next several decades, is estimated to be between $25 trillion and $55 trillion.  Considering the fatal damage our current, relatively trivial financial crisis apparently came within a few hours of triggering, this sounds like a lot of money.

When this massive bubble bursts, not even the stolid American taxpayer will be able to backstop the crash. Unfortunately, heading off this coming healthcare tsunami will require us to acknowledge that healthcare rationing is unavoidable


Health Train Confusion

Quote of the day:
Calamities are of two kinds: misfortunes to ourselves, and good fortune to others. - Ambrose Bierce


Confusion reigns in the financial markets.....do you really want the government making health care decisions for you and your family??

Imagine this scenario:

" The U.S. Department of Disease Extermination today announced a freeze on all appendectomy's.  Future's on hemorrhoidectomies decreased immediately after this announcement, while the Fed was arranging a bailout for UCLA Medical Center. "

We have a less than perfect health care financing system..no doubt about it, yet it functions.

Thursday, September 25, 2008

Health Train Discounts--at last

Illinois Law Compels Hospitals to Give Uninsured Patients a Price Break

Posted by Jacob Goldstein

Nobody pays list price at hospitals — except the uninsured. A new law in Illinois will change that for many families, the Chicago Tribune reports.

The law allows hospitals to charge patients for the cost of care, plus a mark-up of 35%. That may not strike you as a fantastic bargain, but it’s still a lot less than list prices, which can run to two to three times the cost of care. In urban areas, the law applies to those making up to six times the federal poverty level ($127,200 for a family of four); in rural areas where the cost of living is lower, the law applies to those making up to three times the poverty level.

The law also caps total charges at 25% of the gross annual income of qualified families, assuming the patient doesn’t have lots of assets squirreled away.

Illinois’s governor recently issued a veto of the bill that would have raised the income caps (apparently, Illinois law allows for amendatory vetos). But the state’s hospital association — which backed the initial version of the bill — said the higher caps could jeopardize the finances of some hospitals. And this week, the state’s legislature overrode the veto by an overwhelming margin, passing the original version of the bill into law.

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Wednesday, September 24, 2008

Health Train Express Slows down

Quote of the day:
Don't worry about the world coming to an end today. It's already tomorrow in Australia. - Charles M. Schulz


The Wall Street Journal today reported that the annual increase in employer based health insurance premiums increased by only 5% in 2007/2008.  This data came from the annual report of the Employee Health Benefits Survey, published each year.  This is a one source reference which covers a wide range of topics.

The  Bill of Health, a source for viewing an overall graphic of the state of our health system, and it's histor, "how we got here from there", produced by "Good", an internet site.The data for this graphic was obtained from these sources:

CIA World Factbook, Congressional Budget Office,Emanuel Heritage Foundation, Kaiser Family Foundation,National Center for Health Statistics,U.S. Census Bureau, Department of Health and Human Services, World Health Organization.

Tuesday, September 23, 2008

Health Train Bailout

Quote of the day:

No man's life, liberty or property are safe while the legislature is in session. - Judge Gideon J. Tucker


Many blogs this week have turned their attention to the 'dire news' about our economy.  Although it is attributed to the 'meltdown' in the subprime mortgage market we all have a pretty good idea this is not the case.  It may have been the straw that  broke the camel's back , however we have had serious debt problems for many many years.

At the outset I receive at least two credit card offers each week. ( I have not used a credit card for six or seven years. My first medical practice nearly was bankrupted by numerous payors who without much warning reduced reimbursements by 40%, and also quite effectively stole my patient base in the name of managed care. At least four IPAs that I joined and sponsored went belly up in the same time period.  This devastated my long term and short term capitalization and business plan for my ophthalmology practice.

I had a rather nice home which I purchased, but could no longer afford the payments on. I sold it. There was no one there to offer me a bailout.

I had made some foolish decisions thinking that my high income would continue for many more years.  I also assumed nothing bad would happen to my health.  Boy, was I wrong, in both cases.  It was rather humiliating, at the time, and still carries a sting of shame.

I bring this up because I do not see any shame or humiliation in the officials who knew this was coming for some time.  Obviously they hoped they could make it through the first Tuesday in November.

Our nation is how many trillions of dollars in debt...All those hummers,mercedes, lexuses, and million dollar homes...As a nation we have become dead-beats.  Not the vision our founding fathers envisioned for a new country.

In 2001 we were attacked, and had a knee-jerk reaction entering a war that is still ongoing.

That has cost billions and billions of dollars.  It's easy to look back and judge if it was a mistake. At the time it was do it, or we would be wiped off the globe by terrorists.


We were told if we did not do it, the consequences would be dire. Now we are being told the same thing will destroy our economy regarding the 700 billion dollar bailout for the incompetency of some supposedly very bright financiers.

Listen up now....our economy is a wreck,

and bailout will do nothing to improve it.  Printing and finding 700 billion dollars

from some undisclosed source is not an option.  I'm not ponying up additional taxes to bailout some high and fancy financier that cooks books, manipulates markets, commits fraud, and exhibit no fiduciary responsibility for investors, and mortgage holder.

Back in the good old days, when banks were in trouble, they recalled loans, mortgages if their reserves became inadequate. I don't know if they do that anymore.

We have been told for many years that Social Security and/or Medicare would be bankrupt by 2013....The feds were setting us up to blame it on medicine, patients, hospitals....All the while the financial system was already in the tank.  How come no one predicted this one?

We thought Enron, Worldcomm, Charles Keating, and the Savings and Loans fiasco some 15 years ago was bad....you ain't seen nothing yet....As Yogi Berra says, "it ain't over 'til it's over."

Health Train----continued

Last visit I was pontificating about the financial underpinnings of the financial markets and the parallel aspects of healthcare.

One of the most compelling reasons for not adopting a universal payor system  is that it mimic many negative aspects of the federal government....increased regulatory mechanisms, inertia,inbred obsolence, guarranteed employment for civil servants regardless of their "outcomes" and payment for non-performance.

Do you want all that  power and authority placed in the hands of one, or several governmental officials??



(L-R)  The financial 'rainmakers"

Fed Reserve Chairman Bernake & Senator Tom Dodd, Chairman of the Senate Financial Oversight Committee.

All these 'trusted public servants' should be more than disciplined, and perhaps fired.

Imagine now this is the  Federal Health Care Reserve Board.

We already hear  the "blame game"....where were these folks? And where was the United States Congress? There are a litany of excuses..

!!Keep these people out making  health care decisions!

Sunday, September 21, 2008

Health financing = f (financial markets)

Post revised 09/22

Quote of the day:
Where humor is concerned there are no standards - no one can say what is good or bad, although you can be sure that everyone will. - John Kenneth Galbraith



While health care issues are still important, this week's pop quiz has switched to fundamental finance market dysfunction and chaos.  Sound familar?  We in medicine do not have a monopoly on that.  The diagram above relates the increasing mortgage foreclosure rate and the lower red line the decrease in the mortgage financial index.....We could equate this graphic display  to increasing health care utilization vs decreasing reimbursement.  Perhaps some of these financial wizards and tycoons will be applying to medical school as a second career, and we can take over their positions.

The new links over there on the left side will take you to a number of podcasts. 

Universal Payor continues to be promoted by the Obama camp.

My previous post was relatively benign in regard to "nationalizing" our health care financing. However, as the crisis in the 'financial markets' continues to deepen, and our "financial experts"  juggle to make sense of and correct for man's greed, this is a lesson in what not to do. 

Perhaps on the one hand the size of the federal government, and it's ability to print money a la carte gives reassurance to some.

The "Federal government is....large, burdensome, and once set in motion has great inertia and is difficult to steer, or stop. In fact Treasure Secretary Paulson stated that the "Fed" had failed  to adapt to the new global economy and the regulatory mechanism was obsolete.

There are eighty boxes in the organizational chart of the Treasury Department.

Universal payor also embellishes the same risks. A great deal of power in one place, unable to adjust to changing markets, or technology. One of the reasons the United States still fundamentally has the best health science is because of it's entrepenurial bent. The best science and translational science is not the same as the best healthcare.......to be continued

Friday, September 19, 2008

Health Train Design

I am in the midst of restructuring the blog. You may have noticed an increase in the amount of graphics and related links to other sites.  In my mind blogging allows one to freely associate, and click here and there....it is always a surprise where it will take you.   This requires the kind of mind that multi-tasks, and it may be an advantage to be somewhat bipolar.....

Health Train Brain Drain

Quote of the day:
'Tis better to be silent and be thought a fool, than to speak and remove all doubt. - Abraham Lincoln


Now and then Matt Holt will   publish opinions and revelations that are truly 'aha' and are 'I thought of that, why didn't I write it?

True to this idea were the latest comments on his blog, THCB.    Uwe Reinhardt, who is well known in health care policymakers circles, authored a report for New Jersey Governor Tom Corzine

(photo is clickable,, for details)


regarding the state of health care in New Jersey.

The bottom line of this report, which Governor Corzine asked not be published was " Who in their right mind would design a healthcare system revolving around employment? Enthoven and Fuchs  (Health Aff (Millwood). 2006 Nov-Dec;25(6):1538-47), review the rapid growth of plans for the 3 decades following world war II, their peak and decline in the 1980s.

Thursday, September 18, 2008

Where's My Wallet?

Quote of the day:
A good listener is a good talker with a sore throat. - Katharine Whitehorn


Anyone who comes out of the operating room, or hospital is greeted by news of the collapse of the financial markets, and the nationalization of  investment banking, real estate markets, and other institutions.  These large institutions seem distant and not related to our daily lives, however their 'greatness' has been built from the ground up.

Will the same occur to health care....is universal payor really a politically correct synonym for "socialized medicine"?  Of course it is.....

Federal government 'bailouts', emergency loans and subsidies which are capitalized by printing money, fancy terms such as

In brief formal remarks outside the Oval Office, Bush sought to show that the administration is moving swiftly and aggressively by taking "extraordinary measures."

     are all going to be paid by you....the taxpayer. In addition our dollar valuation has collapsed....only supported by   infusions of more imaginary financing from undisclosed printing presses.

The really frightening aspect of this scenario are the things that are occuring now, behind the scenes, the news of which is suppressed and not disclosed.

A year ago we were hearing how fundamentally 'sound' our economy is despite the housing bubble and implosion. 

Voodo economists can graph just about anything. This

graph represents that the cost of gasoline actually has not increased. Sure, tell that to my wallet!!!


Perhaps the "no child left behind" act should have been extended to congress and the administration.  Obviously they cannot do math, or think intelligently. 

In health care we have become "victims"

despite our  proactive, take charge and take responsibilty for our actions drummed

into all of us and  which  at least was ingrained in me during my education and training.

The "thinkers" at the highest level have approached the looming healthcare crisis as controlling costs.  They looked at the total cost of health care, and related it to GDP.  In actuality this is not what they did. They controlled reimbursements, not  costs

Costs to the provider, and hospitals have actually soared due to inflation and the change in demographics..  Providers did a great deal of creative and innovative changing, developing, IPAs, PPOs, even the dreaded "mangled care" models.  This however is a bit like dealing with 'imaginary numbers' such as the square root of minus one.  The calculus of all this is quite imaginary as well.

Politicians know full well that they will be gone in four to eight years (if they are lucky), and will leave the 'mess' to the next "I can fix it"   

McCain  " Don't leave me"   Bush, "It's okay Johnny, just get your hand off my crotch"    Bush, "I'm going to be unemployed, where's my COBRA?"

Aside from all this gloom and doom, on the horizon as the sun sets, and the moon rises in the east is the new "Consumer Driven" Health Care model

RDHC.jpgFrom the Piper Report

Any relationship between this and going in circles is accidental, and the reader should discount any suggestion that this is a circle.

It would all be so funny, if it were not true....

Live, from New York...it's Saturday night!!!!!

Which one of us should meet with Sarah Palin?

Wednesday, September 17, 2008

Focus numero uno

Quote of the day:
Perhaps in time the so-called Dark Ages will be thought of as including our own. - Georg Christoph Lichtenberg


In my last post I began to ask where do we focus? Can we reform the entire health system at once?

I was not quite sure where to go from there, but in the  process of researching for today's article I came across an email from Greg Scandlen, who is affiliated with the Heartland Institute and Consumers for Health Care  Choices.

Patrick Rooney

Click on Photo for Newspaper Article

who is credited with the original idea of medical savings accounts (renamed health saving accounts), recently passed away, but was given a "lifetime achievement award" for his dedication to improving the lot of the disadvantaged.  Here is the program from that award ceremony.

Patrick Rooney Award

Mr. Rooney's bottom line was that he does not want to see health insurers and hospitals 'screwing the consumer'.  Sounds good to me....now how about the physicians???

From my perspective we should all realize our patients are on our side and we must remain their advocates and not allow intermediaries, nor government to divide us in giving and receiving health care.

Tuesday, September 16, 2008

Health Care Reform, Where to Focus

Start the video for some 'listening music' whilst you read today' offerings.

Quote of the day:
One of the first duties of the physician is to educate the masses not to take medicine. - Sir William Osler


Steven Beller, PhD  has been blogging for over five years. His recent blog contribution at Curing Health reveals some important clues to where our resources should go in reforming our health care system. He and I became involved in what was probably one of the first blogs, Trusted.MD, started by Dimitriy Krygylak.  That was a time when I was really interested in RHIOs and the implementation of EMRs.

We need a quality Health Train, one that can efficiently carry as many passengers as possible,

and not leave patients at the train station, waiting and hoping for the next express.  When they get on the train we want them to have a safe and relatively good experience in a time when they are ill.  Additional stresses beyond getting well should not be in their path on that goal.

The buzz word for the last two or three  years has been Health 2.0. Heralded as the next "Apple" of the internet it has found some acceptance, but the business model remains weak, except for some focused applications such as .asp solutions for medical management and electronic medical records and personal health records.  In reality .asp has been around for decades since the days of mainframes.  Today's applications are being directed at patients, and consumers.  Steve Case and Revolution Health have been disappointed in their venture for our 'vision' for the future. Well intentioned, Steve Case invested a good portion of his well deserved treasury from American Online.  Revolution Health is now for sale, having been unable to establish a business model with sustainable income.  This should be a loud example that pouring large amounts of money into an idea does not always bear fruit.  Steve should not be faulted...he is not the first, nor the last to go down that path.  Sound familiar? A lot like RHIOs.

And that's the rest of the story.

Monday, September 15, 2008

PRO(TECH)T Act of 2008

Quote of the day:

Boys will be boys, and so will a lot of middle-aged men. - Kin Hubbard


The role of the Federal Government rears it's head  once again

Capitol Building Picture

with the reactivation of H.R. 6357, as it winds it's way through the Ways and Means Committee chaired by our venerable and staunch representative, and defender of the coiffers of HCFA, Pete Stark of California.

Elements of the draft bill call for:

  • Maintaining the grant and loan programs included in HR 6357;
  • Directing federal officials to coordinate the development of an open source electronic health record;
  • Establishing Medicare incentive payments for health care providers who adopt and use IT systems;
  • Requiring federal officials to study the definition of "health care operations" to determine which activities can be performed with de-identified data and which need patient consent;
  • Preserving most of HR 6357's security and privacy provisions but specifying that the accounting requirement only would apply to disclosure of information stored in EHR systems;
  • Increasing penalties for HIPAA privacy rule violations and requiring a Government Accountability Office study on the "minimum necessary" standard for disclosing data; and
  • Authorizing state attorneys general to file lawsuits to enforce the privacy rule.

A quick observation on my part in reviewing the list of  CCHIT certified software reveals the certified solutions are quickly gaining ground in the market place. Primary care is on the leading edge of  EMR in software applications and will be as the concept of a  "Medical Home"  gains it's foothold.


Sometimes I just want to 'Scream'