Health Train Derailed

Last night’s debate was rather lackluster and uninspiring. Neither of the candidates revealed themselves to be ‘leaders’ and proponents for a glowing American rebound and future. Neither of them painted a picture of creative thought. Rather it was more like a cabinet meeting of officials discussing nickel-dime instructions on how to rescue our country from decline and mediocrity.

McCain’ plan for health reform made universal payer look highly desirable. He totally ignored the issues of escalating health care cost, the uninsured and underinsured.

He ignored public health, children’s health, and geriatric health and no mention about Medicare reform. There was no mention of the burdens of unnecessary bureaucracy and redundant process.

The idea of removing employers from the equation is a double edged sword. The most negative thing about is that many people would not obtain health insurance if it is not a benefit. Who would pick up the vacuum? The tax credit is inadequate and adds another level of complexity, another attempt to manipulate citizen behavior with more tax codes. It does not address the unemployed, either acutely or chronically. In our present system, employers also analyze health insurance plans and offer a menu of plans analyzed by human resources. Would individuals be able to navigate this morass? On the other hand it removes the employer as a negotiating agent in the marketing war of insurers. Individuals would negotiate directly with the insurers. This would change the playing field.

The campaign has drifted away from ‘the measure of the man’. I tend to like some of Obama’s ideas, but am very uncomfortable with the measure of him. Yes, he did some worthwhile work in Chicago with community development, but where does that work leave the ‘rest of us’.

As in healthcare, the economic rescue plan very much depends on details. Without careful thought and advice from those in the system it will be doomed to failure.

In addition to these factors, the financial world seems to have lost all sense fiduciary responsibility, captivated by profit, greed, and golden parachutes. Many of these ‘captains of industry’ should be indicted for fraud and prosecuted to the full extent of the law.

I and many of my colleagues feel a deep sense of resentment when the financial industry can function in a manner that we cannot. If my medical practice acted in this manner, my doors would be closed. I look at Washington Mutual, Wachovia, and others who have been rescued (for the time being) with open doors, doing business as usual. I think their doors should be shuttered. FDIC can insure the depositors, but these banks should no longer be operating. The employees can work for other financial institutions. However to allow them to keep operating under the same name is a travesty of unbelievable proportions.

It seems harsh, but those who lose money will be much more attentive to the banks with which they do business. Obviously leaving this up to regulators who do not regulate has not worked.

If you have made it down to this point in my diatribe, I will close with the following.

Obviously you and I who have practiced in the system for say 5,10,20 years or more no nothing about healthcare, nor how to reform it (at least that is how the politicians, pundits, and allied personel look at it).

(from Distractible Mind..thanks)

I am no expert.....that is woefullly apparent from comments I have received from others.  I will pontificate in other areas. Healthcare is in the ICU, intubated, and without  ADVANCE DIRECTIVES. with no means of ''pulling the plug".

Medical futility.
Who has the power to decide?

Health Train-----I'll catch the next one.

I  am not going to watch tonite's debate. I know all I need to know. In fact I am not going to listen or watch anymore political debates.  There seems to be a total lack of common sense. My criteria for choosing our next President lies in the measure of the candidates.  Listen to Senator Tom Coburn from Oklahoma.

Not their academic prowess

Not their marital history....unless it borders on the promiscuous at this time

Not their race or sex

Not their promises

Not their idea of  health care reform

Not their solution for the economic crisis.

I will not base it upon slick oratory, charisma, and/or rhetoric.

 

I will base it upon their fundamental belief in all the citizens of the United States.

I will base it upon who paid for their education, and fundamental beliefs in the constitution.

I will base it upon who they 'hang out with'.

 

(Photoshop mash up)

I will base it upon to whom they are loyal.

I will base  it upon their life demonstration to America and thier underlying belief system.

 

 

Health Train Overhaul

Quote of the day:

People that are really very weird can get into sensitive positions and have a tremendous impact on history. - Dan Quayle

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

You can forget about major healthcare reform this election cycle. Our current and future elected leaders are hard pressed to correct the financial morass that has developed.  The media is misleading all of us when it places blame on the sub-prime mortgage market.  To hear responsible officials blame this on giving mortgages to people that should not have a mortgage is a blatant lie and misrepresentation of the facts. One of America's ideals has everyone should be able to buy a home. a chicken in every pot and a  car or two in the garage. Perhaps that was true in the 50s when the average home in suburbia was about 19,000-25,000 dollars. This is largely untrue now with average homes costing 250,00 dollars or more in a market where the dollar is almost worthless compared to it's value back then. The cost of gas was about 19-25 cents per gallon.  A MacDonald's burger was 19 cents.

 

Healthcare will muddle along for the time being, unless we see large hospitals or systems threatened with bankruptcy or failure and then they will be bailed out if it affects millions of people.  Don't look for relief for the piddling masses of physicians, and primary care providers. 

You don't need a pile or ream of statistics to analyze our current situation.  Just look at your accounts receivable, and your check book balances.

In fact as William Brody states in the San Francisco Chronicle 

In case you missed it, Great Britain, in response to prolonged complaints from tourists, has decided to move its traffic from the left side of the road to the right, the same way we drive in the United States. But not all traffic. After taxi and truck drivers protested the cost of moving their steering wheels, a compromise was worked out. Cars will drive on the right and commercial vehicles on the left.

They call this the American Medicine Plan.

None of that is true, of course. I offer this nightmarish fantasy to make the point that the United States has the world's only health care system where everyone plays by his or her own rulebook.

In fact, there is no American health care system. You can talk about the British Medical Service or the German medical system or the Canadian national health plan. But when you describe American health care, there is no one system you can talk about. Medicare is different from Medicaid is different from private insurance is different from no insurance.

Individuals in these different situations have different medical experiences - and often different health outcomes.  And for this mess, we Americans shell out $2.2 trillion a year, up from $75 billion just 38 years ago."

What troubles me, however, is that whenever Washington tries to overhaul something that involves a large universe of interest groups, it usually makes things not simpler, but more complex. And complexity is already one of the very worst aspects of American health care.

Has anyone been to a hospital for a procedure and not been confounded by the billing process that followed? No wonder hospitals are repeatedly asked, "Do you go out of your way to hire complete idiots for your billing office?"

In fact, just the opposite is true. Hospitals try their best to hire good people and spend a lot of time training them. But the outcomes are usually abysmal because every insurance plan has different rules, different eligibilities and different coding systems.

Not so very long ago, hospitals dealt with only a small number of organizations that paid for medical care. There was Medicare and Medicaid, Blue Cross/Blue Shield and a handful of private insurers. Recently, I asked my chief financial officer how many payers we deal with today. The number shocked even me. He said Johns Hopkins Hospital has to bill more than 700 different payers and insurers.

They are HMOs, PPOs, MCOs, IPAs and an alphabet soup of other organizations. Each one has its own set of rules for what services are covered, the level of reimbursement and the kinds of documentation and pre-approval required. It is an administrative nightmare.

This inefficiency costs patients tens of billions of dollars each year. Billing, collection and payment administration conservatively represent 20 percent of that $2.2 trillion health-care bill.

When Washington addresses health care reform, therefore, it needs to treat complexity as one of the major symptoms.

How? I don't pretend to have all the answers, but some points are clear. Start with a common format - a national standard for billing and coding - that all payers and providers can use to reduce costs and burdens and make medical bills understandable to patients.

The Barracuda Express

photo source: Bully Pulpit

Sarah Palin, the quintissential girl next door,tomboy, beauty queen, fish, Annie  Oakley, David & Goliath, Esther,...is here in Southern California. Because I am an ophthalmologist I am most strongly attracted by her eye wear...(LASIK SURGEONS, stay away from my girl) and don't even think about using her photo for a testimonial to your "greatness" as a lasik surgeon), a surefire way to tank your practice.

(Marry me, Sarah)

Like most Democrats and Republicans alike, I measure Sarah  Palin by what I observe on the tube.  Some of us are looking for the 'savior' to save us from what is surely a big mess. No fancy words are needed here, and perhaps this is why and what Sarah is all about.  She is not, and has not been a part of the problem  in the lower 49 states.  Give us energy....she has the energy in more ways than one.  We can't measure her by her quantum of expertise in foreign affairs, economics, good old boy networking,the altitude of her formal education,nor her accomplishments in social justice. (does Alaska have a slum, ghetto, or downtrodden masses?  Perhaps the native Innuit's serve that role in Alaska....but we never hear much about them.

Does Alaska have to deal with droves of illegal aliens crossing the frozen tundra in search of work?  Perhaps now that the drill, drill, drill proponents have there way there will be a need for 'cheap labor' that Americans don't want to do'...(we had better start building the bridge across the Bering Strait) 

The last great invasion into Alaska dates back tens of thousands of years when North America was populated by the Asian throngs.

Today I will measure her.  I will be at her speech in the Home Depot Center in Carson, CA , perhaps chosen, by no accident since it is the home of the Los Angeles Galaxy Soccer team.

(close to Los Angeles) to listen, observe, smell, and feel the 'energy' and it's effect on the audience.....a much more accurate assessment than the biased media reports of the cable network channels, who espouse the convictions of their owners.

On Monday I'll be bok (I'm from Caleeforneea) to espouse my humble opinion and return to health care issues.

Health Train CCHIT HIE

News from the Certification Commission for Healthcare Information Technology

On Oct. 1, a certification program for health information exchanges (HIEs) opened for the first time. Recognizing that some HIEs are in an early stage of funding and business development, and wishing to lower the barriers to certification for these entities, the Certification Commission for Healthcare Information Technology has received a limited amount of funding from the Office of the National Coordinator, Health Information Technology, U.S. Department of Health and Human Services, to support certification fee reduction grants for nonprofit, operational HIEs with limited annual revenues. Information about this new 09 HIE program, including the criteria and test scripts, the HIE Certification Handbook and the applicant agreement, is available at http://cchit.org/certify/hie.

Another Debate

 

We are moments away from the VP debates as I watch Dick Morris and Bill OReilly going off in their usual directions. I thought I would squeeze in a bit of blogging....Popcorn and snacks on the right, drinks on the left, laptop where it belongs....on my lap. It generates just enough heat to keep me warm.... I am reflecting on the one hour blog carnival review I just completed.  Some of you are dedicated servants, blogging daily, having guest hosts fill in for you, much like Letterman, Leno and others. Dr. Val has had several Youtube videos dedicated to her meanderings about the blogosphere. (Red Hot Chili Peppers----"I get around" ). Dr Val, are you going to be homeless if Revolution Health get's sold?

  At any moment I expect Kevin Pho to be up there on Bill OReilly.  I am inviting Sarah Palin to do debate with Suture for a Living's Dr. Ribates. 

I happen to like and enjoy Sarah.  We have not done too well with the  politico boys and/or girls from Yale, Harvard, Wellesly College, Sarah Lawrence, and the other elite schools.  Give me a rifle and inexpensive helicopter (and oh yes, a six pack)

The debate is starting....in the words of the Terminator,  "I'll be bok"

Here I am two hours later.  The financial crisis and crisis in healthcare have not changed during these 120 minutes. It is  apparent that Sarah Palin will no longer be an issue for John McCain to prove he did not make a mistake in choosing her to be his vice presidential candidate.  It is now  up to the McCain campaign and the Republicans, indepedents and democrats  who support him to show us what they can do.

Frank Lutz's post debate focus groups all felt that Palin had won the debate.   The overriding theme was "we're mad as hell, and we're not going to take it anymore".  The global gestalt is that we should no longer trust those who say they can lead or regulate us.  No one is taking that for granted any longer.  The regulators failed miserably, allowing less than ethical, and  perhaps criminally responsible individuals and/or institutions to almost bring down the American economy.   We in healthcare have always been suspicious about government capabilities.

Does this also apply to healthcare??  Will healthcare be the beneficiary of this revelation and public outcry? I think as physicians we are responsible to strengthen this connection and mindset.....

Financial Crisis

The recent financial crisis has led me to invoking Norman Vincent Peale's rule"  "Laughter is the best Medicine". for my last several posts.

There has been much angst recently, some directed at others, the Democrats, Republicans, inward, the rich, the poor....and other groups such as liberals, conservatives, leftists, rightists, and centrists who refuse to take a stand on most things.

There are some great thinkers and ideas out there that I and other's read.  Compromise means giving up some thing you  want in order to reach a common goal of bettering the system overall. Are any of us willing to do that?

As far as placing blame...scapegoats are easy to find, and maybe we do need to  clean house to clear our collective conscience.

I thought I would re-post this video....seems apropos for the times upon us.

Health Train Digital Journal Linkage

Today there is a new feature, offered by Digital Journal.com. 

This feature will expand the format of commentary from healthcare to other areas of general interest. It will allow for automatic feeds to Health Train Express and also allow live blogging to other sites from Health Train Express.  I am going to try this for several weeks as a "beta".  Feedback is welcome.

Digital Journal Presidential Blog

Emergency?

Is it too late for a bailout?

Is the patient DOA?

If we do resuscitate, will our patient be in a vegetative state?

 

 

 

The Wall Street Journal Health Blog  and The Health Care Blog mention the trickle down effect of the Financial Market's meltdown. It seems obvious that hospital construction will slow or be delayed if borrowing becomes more difficult.   Hospitals service debt loans and the interest rates have more than doubled the past year.

U.S. med-tech still leads the world, but the larger economy could compromise both the U.S. lead in the sector as well as health innovations.

Will tighter credit slow medical technology innovation?  Big Pharma is also making deep cuts in R&D, unable to justify the tremendous cost of new drugs in the pipeline and increases in  attendant risk with new classes of drugs.

From Consumer Health Care Choices and The Heartland Institute,Greg Scandlen reports,

"One of the few upsides of the current financial markets turmoil and the housing meltdown is that they are likely to put the kibosh on any major expansion of government health programs

People will want to have more control over their own lives and their own fortunes.

Increases in joblessness will raise spending on Medicaid and unemployment insurance,

One interesting addition to the combined financial bailout bill which passed the Senate yesterday is the mental health parity bill  requiring mental health coverage to be equivalent to medical and surgical coverage.

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.

#links

#links

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.

LIFE, DEATH AND HEALTHCARE (trailer)

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. 

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

BAILOUT !