Gloom and Doom

Health reform is not an easy task. If it was it already  would have been accomplished, or at least begun.

The recent financial disasters,including bank failures in the wake of the subprime mortgage market fiasco and secondary consequences in it's wake now have impacted investor firms, and banks.  Even the backup organizations are being threatened and choices must now be made as to which institutions can or will be saved.  In any case you and I will pay for these events, regardless of who is at fault.

Our medical care system has not been immune from this instabilty, nor will it be now and in the future. There is a strong parallel in medical care.  Financial institutions have felt some level of protection by governmental safety-nets.  (Sound familar?)

Our health care financing system and insurers have had the ability to maintain profitabilty and sustainability by their ability to carve out profit each year by forcibly reducing their reimbursement to those providing the actual care, without concern for rising cost, nor deterioration of   care.  The safety nets of medicare and medi-cal are now stressed to the maximum.

Further statements of insurance coverage now belie the fact that even those with "insurance" are not covered. Many providers now are not accepting medicare and many more do not accept medi-caid.  Patients who "have" medicaid are in fact unable to find providers who will see them.  The recent budgetary crisis in California has now totally placed all medi-cal payments on hold.

Tens of thousands of patients in skilled nursing facilities are about to be 'evicted' since their  'homes" will be closed and shuttered.

Costs are being shifted by the surge of non covered patients on medi-cal to private payors because the hospitals have to offset these losses.

There is no doubt that patients are suffering and even dying. More will die if further cuts occur.

Health Train Express Weather Report

Quote of the day:
In the land of the blind, the one-eyed man is stoned to death. - Joan D. Vinge

 

Our health train travels along on it's rails but may be battered or damaged by inclement weather, earthquakes, tsunamis or other uncontrollable factors.

Such an event may be occuring in the U.S. economy. More bad news today about Lehman Brothers, which follows on the heels of Bear Stearns takeover by JP Morgan, and the failure of Fannie Mae, and Freddie Mac which has all been attributed to the subprime mortgage fiasco. And there are rumblings about WAMU as well.

Nevertheless the present U.S. administration insists that our economy is basically sound....FOR WHO? Certainly not for the majority of Americans, nor their physicians.

My previous post regarding a "Health Train" bailout was a fictitious accounting of what would happen to the healthcare market, were the same rules applied to it as the financial markets and general economy. 

I only wish we could be "taken over". (not really)  Nevertheless we seem to be driven close to that feeling of wanting to get "it" off our backs as physicians, and that does not pertain only to the financial responsibilities for operating our practices, both large or small.

What does the catastrophic financial failure mean?

1. In the first instance it threatens many retirement investment accounts, and if your firm is not involved it at leasts makes  you very nervous about your holdings.  (where does all this money go?  Does market value really reflect the value of products produced by companies as they appear on the stock exchanges?  If the experts cannot predict what is going on,and I think they can, but withold information so as not to depress the market further and cause panic.

2. The depression of the markets  carries over to the holdings of insurance companies, and capital markets upon which major hospital construction and operating expenses depend.

3. Short term and long term credit has constricted to the point where capital is not available to most borrowers, especially to  younger physicians who are heavily in debt just from medical school loans.  Most physicians are in a negative net worth situation for the initial five to ten years of practice.

This very much effects the ability for new providers to migrate to underserved, or rural areas, without some form of support by a hospital or community.

The consolidation of the banking industry also effects the ability to obtain local credit, unless the health care borrower seeks credit from a local community source, deeply involved in a local community that shares the need to see healthcare services continue.

..............In my next blog I will review the history of present events and what corporatization has done to your medical care.

Health Train Express Bailout

Washington, D.C. September 10,2008.

Today in an unprecedented action the Department of Justice, Homeland Security, and the Department of Defense    filed an action with the first District Court of the District of Columbia to seize the Department of  Health and Human Services' all hospitals, providers and related interests in regard to the workings of the healthcare system in the United States.

This action came on the heels of the past several months of instability in the health care financing market. All health care providers and hospitals sighed a collective gasp of relief at this move.

Federal officials, HHS, the Department of Justice were unavailable for comment. Telephone calls and inquiries from media sources have not been returned.

Hospitalized patients were 'frozen' in their beds,, in surgery or wherever they  were at the time. All admissions and appointments for physician visits have been cancelled.

One of the terms of the bailout was that all insurance premiums would be made, as usual.  Payments from Medicare, and private payors were suspended.

Today's events follow a several week long crisis in the banking industry, with the seizure of Fannie Mae and Freddie Mac, who by coincidence are inpatients at Walter Reed Medical Center.

Their prognosis is extremely guarded, but the information is protected by HIPAA.

The President in his secure underground bunker beneath the West Wing of the White House held a secure video conference with the heads

of all the aforementioned departments.  He also asked that the White House be declared a "medical home".  A secure encrypted email was intercepted by Homeland Security to

(warning, some may object to part of the contact on this link)

 Dr Jay Parkinsnon for an electronic house call.   This information from an unknown source who insisted on anonymity (because he/she is not authorized to disclose this information)

Both the democratic and republican candidate weighed in with their campaign platform to sovle the challenges of financing health care in America.

Senator MacDonald

stated that it was below his paygrade and rank. (this from a close associate) because Senator McDonald was having a biopsy of his face and  was also seized during the HHS takeover.

Senator Osama Obama

stated that it was beyond his paygrade, but if elected he would be able to answer these issues, since his paygrade would increase.

Governor Palin was unavailble due to a prior appointment hunting, snow mobile racing, and caribou watching.

She would be available for comments as soon as the moose stew was done.

Senator Biden was unavailable because he was 'frozen' while in Bethesda Naval Hospital during his annual physical.

All other calls from patients were told to leave a message, or call 911 if it is really a  life and death situation....However due to the emergency you would need a credit card to reach 911.   They were also told that if their credit score was less than 799 they would be unable to reach 911.

In other late breaking news........................

WAIVER AND DISCLAIMER

The author of this information is solely responsible for this posting, which he patently admits if false. Any assumptions or actions resulting from this posting are not his responsibility and will fall upon the reader.

Health Train Carousel

Does anyone remember those 'merry go round' devices at the end of the railroad line that  revolved so the engines could be turned around. There was a circular table that rotated and one could select one of about 8 garages for the engines as well as turn them around. I haven't seen one lately do they still exist?

 

Why do I bring this up?  Well it is because our health train  engine is on that carousel....spinning and spinning, unable to get off or decide which house to get into, or turn around and go back.

Which way do we go?  Left? Obama.

Right McCain?

Stay where we are? Has anyone factored in what the cost will be to make that change? Will our economy withstand this upheaval in the midst of a real crisis, failing banks, failed Fannie Mae, Freddie Mac and probably a whole lot more we don't know about. Hospitals failing, providers leaving medical practice and one observation is the fact that insurers are "fat" in the midst of all the upheaval with "blue chip" companies such as General Motors, Ford. I wonder why?  Anyone care to comment on that?

There I was in 1964 so pleased to be going into  medicine and not have to deal with obscene corporations, business shenanigans, enjoy caring for patients, and being able to retire.

 

BOY,  WAS I SURPRISED!!

Passengers on the Health Train Express

Quote of the day:

Confusion is always the most honest response. - Marty Indik

******************************************************

Our express train has many cars, pulled by a locomotive. If the train gets too long, another locomotive is added to pull or push the train along with its passengers, and freight.

The train is not as important as the riders, they are the ones on a mission, going to work, going home, going somewhere to be productive, vacation, and enjoy their freedoms in our great country. 

What is critical is that the locomotives are synchronized and pulling together and not in opposite directions.

     I will post some observations about the state of affairs in California, after this diversion. But then again, read this

It does not take a rocket scientist to observe that the political and legislative process is unable to resolve political party differences in transforming health care financing and policy.

Stuck in their universal payor vs open market competition, politicians fail to think out of the box.

Studies abound, with only temporary fixes, based upon budgetary crises, and the fact that most of medical administration is stuck in the early 1960s.

Medicare was ill conceived to begin with, yet now sets a standard for all insurers and payors,  Ironically, when medicare was first legislated it was designed to duplicate standard indemnity health coverage and cover 80% of the usual and standard fee.  (a concept long gone).   As governmental health spending increased, it became  a dominant driving force in the market.  It rapidly fueled inflation in the late 60s through the mid 80s.  The availablilty of 'easy money' for providers and hospitals was a temptation. Not because hospitals and providers were intentionally greedy, nor commiting fraud.  Prior to 1964 there were fewer elderly, and those without coverage fell into the charity safety-net of hospitals, or were given free care....hospitals almost never sent anyone to collections, there was an unwritten word that 'doctors' would figure something out to make sure their patient could receive the necessary attention and care.  It was far from an ideal system, but the diagnostic and treatment options were far less expensive.

So where do we go from here?  I am not against standards set by states, or perhaps the federal government ie  "universal standards v. universal payor.  Let's face it in the United States Universal Payor sound like socialism....not a good word in a republic.  

What is Universal Payor going to cover?

 

Adding to our dilemna is there is no real uniform policy regarding actual health care costs for each patient as related to billing and reimbursement by hospitals.  Different standards apply to different methods of payment....prepaid, capitated, DRGs, and individual contracting (largely influenced by market share)

It is difficult enough to analyze and plan health systems within the context of politics.  Politics should not reign over health care.  As long as there are resources to insure health care availablity politics seems to keep out of the patient's and providers private business.  As soon as there is not enough resources, then the government comes into play.

New Orleans

New Orleans, and the surrounding areas of Louisiana,Missippi, Alabama and Texas are faced with yet another challenge.  However this time they were prepared by being proactive. There was intense cooperation between many disparate organizations for the better good.

What a terrific example and inspiration for success...These folks did not have much of a choice, and what happened was not totally dependent upon financing, under very adverse conditions.

It was a life or death decision to survive.

To me, the comparison between that scenario and health care is obvious.  Can we survive if we do nothing? Can we come together to overcome our disparity?  Will we drown if we do nothing?

CAN WE BE PROACTIVE?

 

Do we have inspirational leaders who can step back, make decisions, or will we continue to have 'committee meetings" and never ending micromanagement, fixes and patches to shore up our dysfunctional health system?

The balkanization of United States health care has created a churning mixture of oil and water, immiscible...the only thing that keeps it going is the constant stirring of the cauldron.  The surge of water over topping the canals reminds me of our system being overwhelmed as well.

Let's pray for the people of the Gulf States.  Volunteer your time, raise funds, give generously to the Red Cross, and your faith based organizations whose mission is to aid the flood victims.

Schedule for the Health Train Express

The Thumbnail Timex

Next time you want to check your timepiece for the arrival of the health train express, you can literally put your finger on it (or thumb as the case may be.  This mini-timex was developed as a design concept for Timex.  This one literally takes "a licking and keeps on ticking".

Okay, a bit off topic, however the political conventions have me at a disadvantage.

Congressional Health Train Express

 

Quote of the day:

The greatest pleasure in life is doing what people say you cannot do. - Walter Bagehot

********************************************************

The response to my recent email newsletter was surprising and encouraging.  I had a response that I wish to share with all of you.

Healthcare in the United States is on the crux of great change. During change we have broken the inertia and are able to more easily transform the system during the period of plasticity.

One proposal is in the U.S. Senate Bill  SB 1019 sponsored by Senator Tom Coburn.  Jim Rowsey MD an alumnus (along with me) of GW Medical School has been working with Senator Coburn. Together, they have prepared this video, which I would like to share with you, and ask you to forward it to colleagues.  Note that there are links in this presentation for you to prepare a letter for your senator.  Click the "A Message......

A Message from Senator Tom Coburn M.D. and Jim Rowsey M.D.

 

You may also notice a change to the logo of the  web site. This was the winning entry from a highly competitive list of suggestions.

I'm sorry the system is too busy to take your call

Quote of the day:

Whenever you have an efficient government you have a dictatorship. - Harry S Truman

 

Beginning Oct. 1, Comcast will put a 250 gigabyte-a-month cap on residential users. The limit will not affect most users, at least not in the short-term, but is certain to create tension as some technologies gain traction.  Whether or not this might extend to commercial usage, such as Health 2.0, or Web 2.0 is not addressed in this announcement from Comcast. Certainly as technological advances proceed it is difficult to predict when 'excessive use' becomes the average utilization. The  use of PAC systems, streaming video, mobile phone solutions, remote at home monitoring, and connectivity among health care sectors is growing exponentially.

In other news,  the FAA suffered a catastrophic breakdown of it's Atlanta operations center last week, causing delays in air traffic routing for several hours.  The FAA's system is outdated and obsolete, despite a decade old effort to upgrade it. The FAA has two centers, one in Atlanta, and another in Salt Lake City. This allows for some redundancy, however, neither center is capable of providing full support without overload. The two videos which follow indicate the seriousness of this problem.

Personnel problems

 

Technical Issues

 

Why is this important to healthcare?  It places in serious doubt whether the federal government is capable  of designing, installing, or maintaining a nationwide system, something Health IT interests, providers, payors, hospitals and safety net providers  should pay close attention.  Governmental process grinds along, inexorably slow, and incapable of keeping up with technological advances that health care depends upon. The governmental role might be to encourage adoption of national standards.

Comments are welcome, and welcome to all our new readers and subscribers. The response has been  awesome!!

The Temple of Obama

Quote of the day:

The world is governed more by appearances than realities, so that it is fully as necessary to seem to know something as to know it. - Daniel Webster

I couldn't ask for a better quote of the day after last night's Graeco-Roman festival.  Where were the gladiators?

 

I have been away from the blog for several days, longer than I realized.  My focus has been on the DNC and RNC conventions.

I did not hear much in the way of real programs, just left vs right, man vs. woman, black vs. white, free market vs socialism, more taxes vs. less taxes, more spending vs. less spending and what it used to be like in the 1950s  which gave me kind of a warm fuzzy

Obama is not just a great orator, but a mass hypnotist. His voice carries with it a kind of "fragrance" that overpowers your ear, and resonates somewhere in the limbic system.  Whatever it is about his voice and resonance we should study it carefully and bottle it, to be re-broadcast at some time in the future when all is about to be lost. I am concerned that somewhere in all that oratory he left us with a post-hypnotic suggestion, which will be unleashed at some unknown time in the future. (perhaps at the polling places in November). So wear your earplugs and eye blinders when you go to the polls.

I had to get that off my chest.  Tomorrow I will be rational again.

Health Train Express is Overheating

Quote of the day:
A Hospital is no place to be sick. - Samuel Goldwyn

Medical bloggers have become recognized by some as "trouble-makers" by the powers that be.....a sure sign of increasing and recognizable influence on health care and it's reform.

My friend Dimitriy Kruglyak also known as "Hippocrates"

on the blog, Trusted.MD writes about his views on medical blogging.

Dimitrity, by the way is not a  physician. While most bloggers and others do not realize it Mr Kruglyak who has received little recognition for his "ground breaking" blog was about four years

ahead of the curve in terms of blogging and aggregated blog commentary.   He also should be credited with developing and producing the first Health 2.0 national symposium.The appearance of the blog may seem funky to all you bloggers, however Mr. Kruglyak was so far ahead of his time that he had to develop his own software to blog.

Trusted.MD  founding contributors have been Rob Lambert,Musings of a Distractible Mind Steve Beller,Quality Advocate)  Sid Schwab (Surgeon's blog), Joseph Kim,  Joseph Kim, MD, MPH. K.Cohn Healthcare Collaboration Blog, yours truly, and others.

Dimitriy makes some very interesting observations, and also how ludricous our medical societies have become and how far out of touch they are with members and non-members.

Dimitriy's unrecognized contribution was  seminal and awesome in regard to medical blogging. (I am certain when he reads this, he will be uncomfortable, shuffle a bit, and blush.). He was prescient in regards to blogs, and perhaps their ultimate contribution to health reform.

The reasons I bring all of this to the forefront is to connect his observations and very accurate predictions about proposed "regulation, and censorship of bloggers opinions". in regard to ethics and conduct.

Elder Train Express

Quote of the day:
It is our responsibilities, not ourselves, that we should take seriously. - Peter Ustinov

Karen Stevenson Brown is an accomplished student and advocate for the elderly.  I thought I knew a great deal about the concerns and care of the elderly when I stumbled upon her web site and blogs....boy was I surprised.

  Karen (she is not the lassie in the cartoon) was stamped out of good old midwestern soil.... the kind of soil where you knew your neighbors well, and in a time where family's cared for their parents and close relatives. The family was more than 'nuclear', it included the electrons, and all participated in sharing and supporting the family unit. Children were expected to contribute,

not only with chores, but for financial needs that in many cases parents could not meet.

Her historical notes outline how we got from there to here, and why our medical financial support system gradually spiralled out of control.

Anyone interested in how our modern day social welfare system(s) evolved and disintegrated needs to thoroughly review her website.

Some of the material is dated, but presents a source for current updates.

History of Long Term Care

• 1776-1799
• 1800-1899
• 1900-1929
• 1930-1939
• 1940-1949
• 1950-1959
• 1960-1969
• Timeline
• Appendix
• Bibliography

One can extrapolate how depersonalized the actual financing of care for parents and elderly relatives has become in the United States.

Karen Stevenson Brown has travelled the country,  holds several advanced degrees and has been involved in long term care for decades.

She has received many awards and media recognition from the likes of  Forbes, Time magazine, and others which you can review by clicking on the above link.

for her unique focus on resources for the elderly, their family, caregivers, long term care administrators, and physicians.

In my humble opinion this is a must read website and reference for any physician who care for elderly or chronically disabled patients.

The Journal of Accountancy credits her with:

"....In 1995 (when the world wide web was still embryonic  she started a Web site to create links to the few resources she could find to help her in her engagements. As more resources began creating their own sites, Brown made more connections, and now ?my site has a life of its own,? she said. Its original plain design has recently gone through a major face lift and organizational upgrade. And the site has become not only a powerful online research tool for clients, government agencies and the general public but also, inadvertently, a marketing tool for its creator. "My practice primarily has been providing services for health care providers. But they don't use the Web much, although consumers of health care for the elderly do; families of the elderly now consult me and my site, for example. So now I work with consumers who ask me, 'Where do I go to get help?'....."

Anyone in health care financial administration needs to read this, and contemplate that maybe the good old days were better.........

Next stop, Grand Central Station

Quote of the day:

No man is exempt from saying silly things; the mischief is to say them deliberately. - Michel de Montaigne

There are many bloggers: who are for more eloquent and gifted writers than I am.

And some are eloquent speakers

I often read their blogs, or columns and think...that's how I feel, or think.....how come I did not say that out loud

or write it down?  Perhaps one of the factors is lack of time....It could involve my whole day and night, if I freely associate....I would even have to write down my dreams....

I think of myself as a visionary and futurist.....so perhaps it is a blessing to those around me that I don't broadcast everything that comes to mind.   It would be like all those teeny boppers marching around the mall on their cell phones...

(who pays for their airtime?), or those loud rude people on cell phones  in the grocery line telling all those around them about their personal grocery list, or their laundry list.  

The measure of success of a blog is to stimulate those who read them...

 

it needs to relate to them, and also be entertaining. It should contain links to other sites, which are authored by really smart, artistic, or silly authors.  I get pretty bored without 'pictures'. I must be arrested at the third grade level... 

By  now you have realized there is nothing about health care today.

I have stepped off Health Train Express at this stop to transfer to another line.

Wait one, my cell is ringing, "hello...no I won't forget to pick up the milk on the way home....luv ya...thanks for calling"

(Ticket Please!)