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Friday, January 23, 2009

Highway Robbery on the Health Train


Willie Sutton, a notorious bank robber was asked, “Willy, why do you rob banks?” Willy replied, “’Cause that’s where the money is”

The WSJ blog recently ran a survey about how primary care funding can be increased.  The survey can be seen here.

The comments I made,

The poll results are most interesting, revealing a fairly even split across the board. This reflects the confusion, and disparate remedies proposed to ’save primary care and health care in general. It also tells the tale that there is no easy solution, at all. Money does not tell the entire story about primary cares negative features. I lay the entire blame on government and insurers. When CLIA came along 20 years ago many physician labs were put out of business, an important revenue source, within their own practice. Imagine a business that was ‘forced’ to use outside vendors for services easily provided in house, providing ‘convenience’ to their ‘customers’….That would be step one. Step two would be to provide additonal necessary services to patients, ie, pharmacy (which may or may not be economically feasible given today’s regulatory environment. Radiology, alternative medicine, accupuncture, chiropractic, et. also throw in  fortune tellers and palm readers (not the IT kind). As Obama once said. “It’s not a matter of too much or too little government, it’s getting it straight and doing it right.” What we need to do is signal the insurers and government that we will no longer serve their clients. Patient uproar would be so great within one month we would see a huge change. How about a 30 day withdrawal from practice. a 30 day vacation….it takes most payers 30 days to pay their bills….we can do the same thing.  If the patients take their medicine they will get better in the long run, no matter how bitter the medicine tastes. 

Comment by G. Levin M.D. - January 23, 2009 at 6:35 am

Monday, January 19, 2009

The Life of Health Train Express

For almost five years now I have been blogging at this site. It has been very enjoyable. And no, this is not a farewell post, nor an explanation that I am too busy, or bored with it all.

Writing is a passion for some people, and computers and the internet give us all a new tool for creativity, networking and publication without all the hoo-ha of a formal writer’s or author’s support group, agents, publicists, book tours,  etc etc.

I have mined more from this experience, as most blogger’s have, than what I have contributed with my little blog espousing my small opinions from my perspective as a grass roots doctor.

I have written the blog with few comments made by readers, however for me it is not all about how many ‘hits’ nor comments I get.  I have refrained from ‘monetizing’ the blog as some have done.  My primary source of income has always remained clinical patient care, my  flirtation with blogging coming in  a very close second calling.  Recently I have been getting more comments and personal comments of how the blog is seen by other bloggers, Twit contacts, Facebook and the other social networking media of the ‘new generation’ of afficionados of tech. 

Sunday, January 18, 2009

Inaugural Train Express



The Health Train Express joins the Obama entrance into Washington, D.C. for the beginning of a new era for the United States of America.

I must confess, I was not a big Obama supporter, with many doubts about the man.  I may have been wrong.  His campaign rhetoric seems distant from his early administrative proclamations. 

What does the new administration bode for us in medicine?  We have seen countless new administrations telling  us now is the time to adopt universal health care.  Congress has never agreed on how to attain that goal, either due to the fact that the devil is in the details, or a lack of conviction that it is correct to do for the United States.

I leave it at this.  “God Speed” President Barak Obama, and good luck to the rest of us.


Sunday, January 11, 2009

Health Train Express Dining Car..."Caramel Macchiato Anyone?"

QUOTES TO MUSIC  (click to listen)

My ego has been inflated (more than usual) by inclusion of Health Train Express in Richard Reece's  700th blog.   This for me is akin to making "Oprahs"  list of books to be read before "End times".

Matt Holt's recent "WONK" summarizes Dr Reeces' consistent eloquence in each of his blogs.  Medinnovation is always a 'must read' and deserves a spot in your "feeds list".  Richard"s  blog and Matt's "The Health Care Blog"  are right up there with my

"Carmel Macchiato at Starbucks !!!

While the holiday season was ongoing this "west coast ophthalmologist" has relocated to a secret undisclosed location on the "Mid-Atlantic" coast. I decided to change risk factors from earthquakes to tropical storms, tornadoes, and an occasional hurricane.



The Warrior Refractive Eye Surgery Program, or in militarese  WRSEP

I am safely ensconsed behind firewalls, encrypted smart cards, and two levels of separate  passwords requiring 12 characters, 2 upper case, and five lower case as well as several  of those special characters, !@#$%&* (which I have to change every 90 days).  The EMR is called AHLTA.  Armed Forces Health Longitudinal Technology Application (formerly CHCS II ; US DoD military health system 

(I could go on and on about this HIT solution, but that is a topic unto itself. So stay tuned.


Thursday, January 8, 2009

Health Train Express--The New Engineer

Tom Daschle appears headed toward an easy confirmation as the head honcho at Health and Human Services, where he would oversee the FDA, Medicare and the NIH. Today, he had a friendly hearing before the Senate’s Health, Education, Labor and Pensions Committee

 imageHe is no stranger to the hall of congress, and most legislators will be very comfortable with him as the  point man, bully pulpit for health reform.

His early pronouncements offer no new panacea, however he does espouse the new politically correct  illusion of "transparency"

Daschle cataloged a bunch of problems with the health system, from the “unacceptable” figure of nearly 46 million uninsured to a “loss of confidence” in the FDA. He of course pledged to work on these problems. Here are some highlights:

Health Reform: In his prepared statement, Daschle said reform “cannot be dictated from the White House and Washington,” but instead must come from the grassroots and must be an open and transparent process. He pledged close collaboration with Congress.

His next pronouncement is focused on the Food and Drug Administration:" 


Unfortunately, there is growing concern that the FDA may have lost the confidence of the public and Congress — much to our detriment. When Americans are nervous about eating spinach or tomatoes or cantaloupes, that’s not good for our health and it is terrible for our farmers. When nearly two-thirds of Americans do not trust the FDA’s ability to ensure the safety and effectiveness of pharmaceuticals, the result is Americans may hesitate to take important medications that protect their health. This is unacceptable."

National Institutes of Health:


The NIH’s funding has been flat in recent years, reducing the NIH’s “buying power,” Daschle said. There’s been a sharp drop in success rates for research grant applicants, with the figure at 10% for many of the institutes, he added. The NIH has also “suffered from some instances of people putting politics before science.” He said he’ll work to “strengthen NIH.”

None  of us can do anything but wish him the 'Best of Luck" and determination.


Thursday, January 1, 2009


2009 brings nothing new in health care.  Tom Daschle invited me to hold a group meeting t several weeks ago to discuss what is on the minds of the country ( a kind of town meeting forum) and present a group consensus of what should be done to reform health care and health care financing.

Today I received an email from him requesting my report, in a survey form. 


Obama-Biden Transition Team

Dear Gary,
Over the past two weeks, thousands of people representing all 50 states and every corner of the country have hosted health care discussions in their homes and communities. Just this week, I attended a discussion hosted by the Fire Department in Dublin, Indiana, and one hosted by a Senior Wellness Center in Southeast Washington, D.C.
Leading your discussion was the first step. Equally important, we want to hear back from you. I learned so much from attending discussions this week, and we want to know about your discussions, too.
The President-elect has asked me to share your feedback from these discussions -- that's why your submission is so essential.
Please tell us how your discussion went by visiting We need to hear from you as soon as possible -- by Sunday, January 4th, 2009 at the latest -- so we can prepare our report for the President-elect.
Both President-elect Obama and I are committed to reforming the health care system from the grassroots up -- and leaders like you are crucial to that effort.
I'm looking forward to reading your submissions about your Health Care Community Discussions.
Thank you,
Tom Daschle
Department of Health and Human Services

Matthew Holt on The Health Blog accurately assesses this effort and mirrors my personal opinion on the liklihood of a political solution for what ails health care in America.

Matt's  takeaway points are:

Like legions of other wonks when I discovered that Tom Daschle was going to be Obama’s point guy on health care, I sent off for a copy of his book Critical. It’s a fast and easy read, but in its examination of the problem it doesn’t add much to superior books on what’s wrong with health care (much of the first section reads like an undergrad’s attempt to summarize Jonathan Cohn’s Sick) and there are some pretty weak logic flows and basic editing throughout (he refers to the book Uninsured in America on p155 as though it’s already been introduced before it actually gets introduced on p161). But ignoring all that, what does Daschle suggest we actually do?

The ill-fated & exclusive White House study groups of Feburary to May 1993 are therefore only to be repeated in set of window dressing home study groups & Internet bulletin boards—who’s participants will have as little actual positive impact on health reform as Ira Magaziner did in 1993–4. Still the process now is notably open.

Daschle likes and wants to see more of. Mental health parity is one, dental insurance is another, and long-term care a third. To be fair these are three areas crying out for a better solution, but Daschle doesn’t make it clear how we’re going to expand the current definition of insurance to include them. In addition these are areas for which Medicaid is the current de facto half-assed solution. Medicaid is a program Daschle likes, while many health policy wonks (well me anyway) think it should be abolished and rolled into a genuine universal social insurance system, or at least (as Paul Krugman suggests) be Federalized and thus removed from the vagaries of state budgets.

But the actual coverage solution Daschle proposes, which is pretty similar to the ones emanating from Clinton & Baucus are basically to expand FEHBP and give it both a Massachusetts Connector-type role and include in it a buy-in to Medicare, and to impose a pay or play option onto employers. Somehow he’d also expand Medicaid and S-CHIP, and then add to all this an individual mandate with subsidies to those who can’t afford to buy-in to FEBHP. The whole thing is tied together, sort-of, by a Federal Health Board

Daschle is damn lucky that he didn’t call his board Fannie Med, but he’s also unlucky in that he links it to the success of the Federal Reserve at a time when that “success” is looking, shall we say, shaky. However, the main role of the Federal Health Board would be as a cost-effectiveness review organization with teeth—in that Medicare, Medicaid & FEHBP would all be bound to follow its guidelines.

So the problem with this always comes back to two things.

One; most of the uninsured are working poor and their employers are the NFIB small employer crowd who are all for health reform until they figure out that it means they have to pay for it. Even despite the incredibly confused rhetoric coming out of NFIB lately, my guess is that only a puny Massachusetts type “pay” fine ($213 or so) will be little enough to get them to willingly back a public and compulsory plan for their employees. And of course at that point all but the richest of the remaining 55% or so of small employers who offer coverage will ditch it too, meaning that the public subsidy for the working poor to get insurance will have to be much greater than Daschle thinks. Not to mention the continuing administrative nightmare of figuring out whether someone should be in Medicaid, the new plan, or covered by their family member.

Second, while it may be getting harder and harder for the Sally Pipes of the world to get people worried about rationing when it’s clear that we already have it here but that they don’t really have it in Switzerland, Germany or France, the Federal Health Board will be fought tooth and nail by the industry. Sally Pipes is the author of "Miracle Cure"

As I’ve been saying for a long time, to rationally rationalize the health care system, we need to make cardiologists in Miami behave like cardiologists in Minnesota with a consequent impact on the incomes of doctors, hospitals and stent & speedboat salesman in high cost areas (Yes, Jeff, I do mean Louisiana, New York, Los Angeles and Boston too). If the Federal Health Board has teeth, that’s what it’ll do, and the AMA, AHA, AdvaMed, PhRMA et al know it.

So my guess is that the Federal Health Board, if it gets established, will get defanged by lobbyists immediately. The consequence of that is that the mish-mash of an “expand what we got now” system will cover a few more people at a lot more cost (as has been the Massachusetts experience). That’s OK because suddenly we’re rich (or at least suddenly the government is pretending it is!).


There is much more to be read on Matt Holt's Health Care Blog.