Tag Archives: healthcare

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America and Healthcare Reform by Greg Henry

Examining the American Proposition

Health care debate must necessarily begin with a discussion of America’s root political philosophies.

As summer progresses, hardly a day goes by that doesn’t challenge America’s hegemony, from the Gulf of Mexico turning into an oil slick to the Iranians amassing nuclear weapons. In the midst of the chaos, we have to live with a health care reform bill which has nothing to do with health care and virtually nothing to do with reform. The reason I believe that America became so polarized and divided on this issue is that we have forgotten the philosophical basis on which our country was built. This is not Europe, Canada or Mexico. This is a unique country once known for greatness and now known for ambivalence and timidity.

To properly review our origins, I believe we need to go back to a few key philosophic texts. This year marks the 50th anniversary of the publication of John Courtney Murray’s landmark book We Hold These Truths; Catholic Reflections on the American Proposition. Murray’s four pillars of the American experience will help form the lens through which we should be able to view any and all governmental activities. The first of these inherited truths is that we are a nation of judgment and one which is dependent upon individuals to be above the lies of politics. This view, much like that of Edmund Burke, distinguishes the Anglo-American political tradition from that of continental Europe, which subjects the individual to the whims of the state.

It is very interesting to note that everyone in the United States argues about the individual’s rights, but no one ever speaks of the individual’s responsibilities. What may seem good, kind and reasonable today may bankrupt another generation. Adding money to social security benefits may seem a good thing to do at this time, but may be putting a noose around our children’s necks.

The second foundational truth of the American proposition grew out of the Christian middle ages. It is the principle that just governance exists by and with the consent of the governed. Social pluralism of the middle ages held that the individual put society ahead of government. This is one of those truths which is self evident to everyone and yet practiced by no one. Everyone is looking for an answer and a handout. No one is looking to do any work or to give anything up. “A government that can give you all that you want must take from you all that you have.” The balance of these equations is out of kilter in America at this point in time.

The third truth of the American proposition as quoted by Murray is, “the state is distinct from society, limited in its offices toward society.” Society exists prior to the state. Long before there was the United States of America, long before there was any governmental organization, there were people helping people. There were people drawing reasonable limits, people deciding what they could afford and what the best possible outcome could be. They also understood the idea of futility. Where have these people gone? This medieval distinction between the society at large and its organizational structure, its “government,” need to be put into line so that physicians can enter the discussion with reasonable scientific information, which is balanced with a humanistic approach to the care of their patients.
The fourth component of Murray’s proposition is the profound conviction that only virtuous people can be free. Murray knew that there are no guarantees about the success of freedom. “Freedom can dissipate into license, private license into public decadence and decadence into chaos.”

“It is not an American belief,” Murray wrote, “that free government is inevitable. Only that it is possible. Moreover, its possibility can only be realized when the people as a whole are inwardly governed by recognized imperatives of universal moral law.” This should be an inherent cultural consensus. But unfortunately, there is no inherent cultural consensus. There is no more inherent understanding of limitation. It is only about “me”. We have raised a generation of people who cannot look beyond themselves. I, fortunately was raised by a generation that were molded by two forces, the Great Depression and the Second World War. They understood much clearer the necessity to come together to view the common good. The common good is never a single entity, but it is a moral and ethical internal basis, which says certain things need to be accomplished and others must be put aside.

The public square has lost its luster. The place where intelligent discussion can happen on any of these issues has disappeared. We are surrounded, on all sides, by nitwits of negativity. All you have to do is watch cable television to realize that the grand old days of true intellectual discussion have disappeared. There was a time when William Buckley carried on brilliant debates on his television series, Firing Line. Where are the Buckleys of today? We are surrounded – and I use that term advisedly – by neebobs who can no longer structure sentences or take down ideas in a clear manner without launching into ad hominem arguments as opposed to the ad factio discussion. It is an embarrassment to hear the fundamentally mean-spirited discussions on both the left and right, which stop us from carrying on a philosophical discussion of what will be the base of this government. We have broken into armed camps, which have an immediate negative response to anything said on the other side.

What is the state of understanding ourselves? Murray commented that “the complete loss of one’s identity is, with all propriety of theological definition, hell. In diminished forms, it is insanity, and it would not be well for the American giant to go lumbering about the world today, lost and mad.” What we are watching is the decline of one of the great cultures of western civilization, and until we are able to reestablish the firm pillars on which government makes decisions, there is little good that can be said about the future of health care reform in America.

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Steve Wynn Interview

Short interview with Steve Wynn, Hotelier and Real Estate (For those of you who don’t know who he is, he built the Mirage, Bellagio, Wynn Resort, and Encore, as well as casinos in Macau). If you listen to this interview (short & to the point) and nothing else today, you will be better informed than your neighbor about the state of the union.

http://www.infowars.com/steve-wynn-takes-on-washington/

A friend sent me this message and link. Remember that I am not political by nature, but Steve Wynn very succinctly paints that picture of the future of U.S. healthcare and the state of our union.

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Voluntary Incapacity

Emergency Medicine News:
April 2010 – Volume 32 – Issue 4 – p 8
doi: 10.1097/01.EEM.0000370749.07758.6d
Second Opinion

Second Opinion: Capable – and Proud of It – in a World of Voluntary Incapacity

Leap, Edwin MD

Free Access

Those of us who work in emergency care are often deemed insensitive by others. When we rant about the situations we see, sensitive people genuinely believe that we’re cold, uncaring, or burned out. I have been accused of ultraconservatism, right-wing lunacy, being judgmental (the worst insult a post-modern can muster, by the way) and of being a greedy, Mercedes-driving doctor. (I drive a pickup.) Someone even said my newspaper readers should ignore my opinion about medical finances because I was just “po’mouthing,” a Southernism that implies I was making my situation sound dismal when I was actually quite well off.

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While I’m sure that a few physicians are, in fact, cold and uncaring, most of the docs I meet are anything but. What they are, however, is possessed of the remarkable clarity about humans that can only come from working with actual people rather than theories or ideologies. It’s an insight that cannot be achieved in the purely academic world, nor is it attainable in Internet chat rooms, but it isn’t, as I long suspected, just doctors who deal with reality.

I often speak about our struggles with a dear friend and fellow church deacon who is a manager in a local grocery store. My friend is as kind a man as you’ll ever meet. Devoted to family, friends, and God, he volunteers at a local elementary school, spending time with at-risk children. He comes to church early to pray for the many things that burden his heart. He would literally give you the shirt off of his back. And he’s fed up with the abuse he sees in his grocery store.

He told me, “Ed, I see people using food stamps to buy food I could never afford. And I have a good job!” He recently held forth about a woman using her WIC (Women, Infants, and Children program) card to buy six gallons of milk at once. When he half-jokingly asked what she did with all of the milk, she pointed to a toddler and said, “She drinks all of it.” Later, leaving the store, the customer was heard to say, “What does he care? He ain’t payin’ for it!” Except, of course, that he is.

My friends who are deputies and highway patrol officers feel the same, as do many of my friends whose work as attorneys puts them in contact with the welfare and social services systems. They are often frustrated by the abuses they see, by the parade of bad decisions, and by a bureaucracy that almost seems to encourage and reward the abuse of benefits and services while rarely elevating anyone.

One of my own favorite gremlins is disability. Many of my patients seem to see disability as a career goal. A friend of mine is a school counselor. When she recently asked a young high school student what his post-graduation plans were, he never missed a beat. “Guess I’ll get disability for my nerves, like the rest of my family.”

The thing that makes those outside our circle think we’re bitter is that stories like the ones above drive us crazy. Just like patients who come to the ED for routine pregnancy tests, who ask for prescriptions for Tylenol, and who seek Family and Medical Leave Act forms for ankle sprains. In the same way as the diabetic who refuses to get a $4 prescription at Walmart but regularly goes to McDonald’s before coming to the ED.

There are doubtless well-meaning people who will read this and still marvel at our insensitivity. So I was doing a little reflection on what it is about these situations that frustrates us. Is it, after all, about the money? Are we just mad because we aren’t being paid? Well, that can’t be it. My disabled and Medicaid patients all have insurance. I’m paid for seeing them! Maybe not a full market value, but something is better than nothing.

Is it elitism? Do I consider myself better than these folks, who are often poor and uneducated? Probably not. My faith teaches me that we’re all the same in the eyes of God. And my own grandparents were laborers and small business owners as well as subsistence farmers. I have no animosity toward those who struggle.

And then it hit me! Those who struggle! I like it when people struggle, not in the sense of hopelessness or crushing misery, but meaning those who try, who set goals and go through life trying to be better, happier, more successful, more resourceful, more independent. I’m happy to help those who try, and happy to help those who are actually in need. I’ll gladly give care to the truly sick. I’ll stay late, bend over backwards, beg and borrow to do whatever it takes to help them. For those who try? Anything. If they’re trying to do what’s right, trying to get healthy, trying to rise out of generational poverty, trying to recover from an accident or mistake, a prison sentence, or a disabling injury, I’m honored to be there for them.

What bothers me, what bothers us collectively, is not that people need us. It’s not even that people need us for free. It’s that they have begun to worship at the altar of incapacity and what wise men of old called sloth. We are an overmedicated, undereducated nation bent on proving that we cannot, rather than showing that we can. Having inverted the ethics of our forefathers, our goal is no longer autonomy, but dependence.

We have abandoned the sense of guilt that in the past made our citizens try to achieve on their own to avoid being burdens. We have, in fact, abandoned the entire idea of guilt in exchange for a kind of social lovefest, where anything goes as long as we want it.

And nowhere do we see the results of this experiment more clearly, more painfully, than in the emergency department. Young and old alike swamp our departments, convinced that someone owes them money and compassion for their own dysfunctional life choices and beloved incapacity.

It isn’t that we’re burned out. It isn’t that we’re cold. It’s just that we understand better than most what it means to try. No one told us that not trying was an option. And we’re just weary of being responsible for an endless parade of patients who believe we owe them something and who consistently refuse to do anything for themselves.

So don’t let anyone call you bitter, shallow, greedy, or anything else. Gather your friends, business people, police officers, and social workers; collect their stories and pass them on. Explain that you aren’t the only person frustrated with our deteriorating social situation.

And be proud that in a world of epidemic and voluntary incapacity, you remain capable and proud of it.-Dr. Edwin Leap

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Anticipatory Guidance

This is something that I don’t do enough of: ANTICIPATORY GUIDANCE.  It falls into the adage: Tell them what you are going to tell them, tell them, tell them what you told them.  One of our main roles as health care providers is to ease pain and suffering AND anxiety.  A great way to do just that is to tell your patients what they should expect while in the emergency department and beyond. This is another great article gleaned from Emergency Medical Abstracts (I have added the audio discussion from the Emergency Medical Abstracts for your listening and learning)

A PROGRAM OF ANTICIPATORY GUIDANCE FOR THE PREVENTION OF EMERGENCY DEPARTMENT VISITS FOR EAR PAIN

McWilliams, D.B., et al, Arch Ped Adol Med 162(2):151, February 2008

Let me know what you think.

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Haitian Earthquake Survivors Praise God

A friend and partner of mine just shared this video he took when he was caring for Haitian’s in an orphanage converted to a hospital. The Haitian’s spontaneously errupted into praise songs to God.

Also here is a link to a powerful letter from a surgeon who just returned as part of Samaritan’s Purse…

Haitian Earthquake Survivors from Jim Keany on Vimeo.

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Healthcare Reform: The Root of the Problem, Part 3

I remain relatively apolitical. I asked my eye doctor recently what he thought of the healthcare proposals. Little did I know that he was REALLY well read on the issues and founded a group to reform healthcare in the U.S. (http://www.afcm.org) WOW! He pointed me to a 3 part (less than 30 minutes total) youtube video lecture. I HIGHLY recommend listening. It was thought provoking and some of it was shocking (I didn’t know). As always, share your thoughts with us…

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Healthcare Reform: The Root of the Problem, Part 2

I remain relatively apolitical. I asked my eye doctor recently what he thought of the healthcare proposals. Little did I know that he was REALLY well read on the issues and founded a group to reform healthcare in the U.S. (http://www.afcm.org) WOW! He pointed me to a 3 part (less than 30 minutes total) youtube video lecture. I HIGHLY recommend listening. It was thought provoking and some of it was shocking (I didn’t know). As always, share your thoughts with us…

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Healthcare Reform: The Root of the Problem, Part 1

I remain relatively apolitical.  I asked my eye doctor recently what he thought of the healthcare proposals.  Little did I know that he was REALLY well read on the issues and founded a group to reform healthcare in the U.S. (http://www.afcm.org) WOW! He pointed me to a 3 part (less than 30 minutes total) youtube video lecture.  I HIGHLY recommend listening.  It was thought provoking and some of it was shocking (I didn’t know).  As always, share your thoughts with us…

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Doctor Senator’s Opinion of Healthcare Reform

Sadly, I think it is too late.  This interview should bring us all chills down our spines. 

30 Minutes with Dr. Coburn
Tom Coburn, MD (R-OK) is one of only two physicians serving in the US Senate. He’s known for his opposition to earmarking and has taken a strong stance against the current health care reform bill. EPM tracked down Dr. Coburn to ask him why. 
 
Interview by Mark Plaster, MD
 
 
EPM: We understand that you oppose the current health reform bill in the Senate. What do you see as its major problems?

Sen. Tom Coburn: This bill will ultimately divide the loyalty of the physician, not to be a 100% advocate for the patient, but to be sure and cover their backsides, so they don’t get in trouble with the government. The cost comparative effectiveness panel? You’re going to have to do things the way they think you need to do it. This [bill] guts the art of medicine.  For 80% of the people that will be just fine. But we will have changed our focus to the cost of medicine from the health of the patient. What’s the other bad thing about the bill? It’s going to raise everybody’s taxes. It’s going to raise everybody’s costs and it’s going to raise everybody’s insurance premiums.

EPM: Assuming that we need to control cost, what’s wrong with how this bill goes about accomplishing this task?

Coburn: The assumption [in Congress] is that we need to spend more money to control costs.  That’s ridiculous!  One in three dollars that we spend in health care today doesn’t do anything to help people get well or prevent people from getting sick.

I have a friend who now practices medicine. He’s an internist and a great doctor. A year ago he quit taking Medicare and Medicaid. All he does is cash business. He let four people go in his office. He only has one employee now. Those four people weren’t doing anything to help people get well. They were doing the business of medicine rather than the health care of medicine. Truly, 50 to 60 percent of the overhead of every health care organization is spent complying with the rules and filling out the paperwork. [My friend] now sees fewer patients, says he’s practicing the best medicine he’s practiced in his life, and he makes the same amount of money. His prices are very reasonable. And if someone doesn’t have money, he’ll still take care of them.
 
EPM: The supporters of this bill claim that it will increase the number of family practitioners in this country.  You are a family practitioner.  Do you agree?

Coburn: No. It will not increase the number of family practitioners.  This bill does nothing to pay family practitioners more, it only helps them pay off their loans. One in fifty doctors who graduated from medical school last year went into primary care. Just one in fifty. So how do you incentivize people to go into primary care? You pay them more! What [the government] is going to do is provide all of these subsidies for loans, but [medical students] won’t go. They’re going to realize that they can spend one more year in residency and earn twice or three times the earnings over the long haul.

EPM: What do you think will happen if this bill passes?

Coburn: Forty-five to fifty year old doctors are not going to play this game.  If they have a way to retire, they are going to do it.

EPM: Will we have more specialists or fewer?
   
Coburn: Medicare has created an absolute shortage of cardiovascular surgeons. They pay about $1,200 for a heart bypass now. These guys have 8 years of post-medical school training. They have 12 years of training in medicine before they ever get a start earning a penny. And now what used to be a $3000 procedure is now a $1500 procedure. The program at the University of Oklahoma shut down for cardiovascular surgeons because they couldn’t get anyone to go into it.
   
EPM: Senator Reid claims that this bill will cover everyone, cut the deficit and save lives.  What do you say?

Coburn: If you use real accounting, this is a $2.5 trillion bill that will run massive deficits. Here’s why. Number one, Congress will never cut Medicare. That’s $500 billion more. Number two, the doc fix. The doc fix will get fixed, but they’ll never cut spending somewhere else to pay for it. That’s another $274 billion. Then we’re going to increase those eligible for Medicaid. And we don’t have the money to pay for it. And then finally, everything you buy in health care now is going to get a new tax on it. Your drugs are going to get a new tax, your insurance is going to get a new tax, your medical devices are going to get a new tax. And then finally, since they charge you only $750 to not have health insurance, what do you think healthy people 40 and under are going to do? They’re going to take the $7000 or $8000 that they were contributing to their employer and they’re going to keep it, pay the $750, put $4000 away every year and if I get sick, then go buy the insurance. What’s that going to do to the insurance industry? The healthy people are not going to be in the pool. So the pool is going to be smaller and the pool is going to be made of sicker, older people. So everybody’s premium is going to rise. So not only are we going to have massive deficits from it, but the price that everybody pays is going to go up. Plus, we’re going to tax small businesses, we’re going to tax individuals, we’re going to raise the Medicare tax and then take the money from Medicare – which has a 75-year unfunded liability of $39 trillion – and create another government program.   

EPM: Can you explain your numbers?

Coburn: Over the next ten years, 55 million more Americans are going to go into Medicare. The baby boomers. My generation. We’ve been paying in, but the amount of money to pay for our health care is in deficit by $39 trillion over the next 75 years. In other words, that’s what we’ve promised but don’t have in the bank. And that’s the differential after the taxes are collected. So if you’re going to raise the Medicare tax, it ought to go to fund that differential rather than create another government program.
The government controls 61% of health care now, if you add up Tri-Care, VA, Indian Health Care, federal employees, etc… Tell me one of those that is efficient, working on budget and delivering the care that we want them to have. None of them. And we’re going to put the rest of the care in the government’s hands?

If you were to go back and look, when did health care inflation start at 2.5 times what the regular CPI was? When they instituted Medicare. Why? Because we have this disconnect between the purchase of health care and payment.

EPM: So how do you bring cost under control?
 
Coburn: First of all you incentivize tort reform throughout the country. You’d save $100 billion on health care tomorrow. The numbers on malpractice suits are that 80% that get filed get dropped because they’re just attempts at extortion. Of the 20% that either get handled or go to court, only net 3% end up being found in favor of the plaintiff. And the ones who win, who have legitimate injury, only get 40% of the money. And it takes forever for them to get compensated. So one of the ways to [reform] would be loser pays. Go to English law. You would save $100 billion the first year you had that in effect.

 
EPM: Would that really change the way we practice?
 
Coburn: It would over time. It would take 10 or 15 years for the changes to happen on the physician side. We’ve developed this habit [of defensive medicine] because of being sued inappropriately.
EPM: What other ways can we lower health care costs?

Coburn: Create real competition and transparency in the insurance industry. And you can only do that by allowing people to buy what they want. So if I want to buy a $25,000 deductible policy and I can find someone in this country to sell it to me, I can buy it. I can’t do that now. I live in Oklahoma. The highest deductible policy you can buy is $7500. Also, allow associational group health plans. Let small businesses come together and pool their resources and contract out on a broader base of indemnification. Small businesses have no buying power, so you allow them to combine. Finally, allow the markets to function. The problem with all of these bills in Washington is that they’re government centered, not patient centered.

EPM: You don’t seem very optimistic about your colleagues in the Senate.


Coburn: What ails Congress today, in my view, is people who are making decisions at this level who have never done anything except politics.  They are wonderful people, they care about the country, but they are clueless when it comes to common sense.

I don’t think anyone with less than 20 or 25 years of experience in life should be in politics; someone who has been around the block and knows how to prioritize things. The problem with Washington is that they don’t want to prioritize anything. They just want to keep charging it to our kids.
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We often ‘find’ what we are looking for

Kiderman, A., et al, Arch Intern Med 169(5):524, March 9, 2009

METHODS: These Israeli authors evaluated the influence of bias introduced in a patient history on physicians’ perceptions regarding clinical findings and actual management. Healthy actors visited 32 clinicians (30 trained outside the U.S.), reporting a history consistent with viral infection (headache, fever, cough and runny nose for two days with throat discomfort and hoarseness on the day of the visit) or bacterial infection (sore throat for one day with headache and fever with malodor of the mouth but without cough or nasal discharge). None of the actors had physical findings consistent with illness, as confirmed on pre-visit evaluations and photography.

RESULTS: The experience level of the participating physicians ranged from 5 to 32 years (mean, 19 years), and 13 of the physicians were board-certified in family medicine. The physicians recorded slight, moderate or severe pharyngeal erythema for 41%, 34% and 6% of the actors presenting the viral script, and for 22%, 31% and 22%, respectively, of those presenting the bacterial script. An exudate was recorded for 6% and 25% of the actors presenting the viral and bacterial scripts, respectively, and lymphadenopathy was recorded for 16% and 26%, respectively. Throat culture was done for 47% of the actors presenting the script consistent with viral illness, and for 73% of those presenting the bacterial illness script, and antibiotics were prescribed for 21% and 79%, respectively.

CONCLUSIONS: These findings demonstrate that physicians often “find” physical findings consistent with what they expect to find, based on a patient’s history, and that this appears to be true regardless of the level of physician experience.

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Tribute to ER Nurses

This is a great tribute and article pointing out the hard work and compassion of our ER nurses:

“I heard a guttural scream,” Rich says, “and a man was handing me his lifeless son.”

“How old?” I ask.

“Nine months. We worked on him for over an hour.”

Rich moves his chair, coughs. It’s freezing in the conference room. [Note: For privacy, nurses are mentioned only by first name.] The muffled din of the emergency room is audible through closed metal doors. It’s 7 a.m., and Rich’s 12-hour shift has just ended. “I flashed to something I heard once about how a casket doesn’t weigh very much—just enough to break a father’s heart,” he says, “and I lost it. I’m standing there, between beds one and two holding that dead baby, and I’m sobbing. I am in charge, and I’m crying.”

As an 11-year volunteer in Cedars-Sinai Medical Center’s emergency room, I’ve seen close up what ER nurses deal with. It takes rare emotional courage not to burn out when you know that every time those doors open—whether you are working triage in front, where a guy may stumble in with a heart attack, or in back, where paramedics may race in with a girl who has been knifed or shot—it’s bad news. Then there’s the physical strength required to survive 12-hour shifts with two half-hour breaks and 45 minutes for lunch. ER nurses never sit. But it’s the children—every ER nurse will tell you—who take the biggest toll.

“For a very long time,” Rich says, “I viewed it as a badge of honor—How much crap can I take? How much horror can I see and not show emotion?” He clears his throat. “But you can’t keep stuffing it down; you have to deal with the emotion.”

Rich has been a nurse for 22 years. He has a 12-year-old son. There are 98 nurses in Cedars’ ER. Their ages range from 24 to 67, and they are as different as heavy metal is to polka. What they share are guts and a desire to give. “I was an operating-room tech in the army. My CO said, ‘Nursing?’ And I thought, Maybe,” Rich says.

He is big and bulky, with soulful eyes and a wild sense of humor. When I ask why he really became a nurse, he jokes, “I liked the cute little hats, the white nylons and the sensible shoes.”

Rich was diagnosed with leukemia last year in his very own ER, when he showed a doctor some large bruises on his body. The doc ran tests while Rich was on shift and returned with the diagnosis. The story goes that he asked the doc if he could finish his shift so he wouldn’t get docked pay. After eight months off, five rounds of intravenous and oral chemo and too many bone-marrow biopsies, Rich is back working nights. I don’t know how he does it. I don’t know how any of them do it.

“It affects your soul,” Melissa says. She could be called the queen of trauma, having done 20 years in what she terms “the knife and gun club” at St. Luke’s Roosevelt Hospital in Harlem and five years in Newark, New Jersey, before coming to L.A. “Newark made New York look like kindergarten,” she says.

Hearing Melissa’s accent is like flying to N.Y. and walking into Original Ray’s. She recalls a guy “who was having a big heart attack in room nine…In the middle of his pain, he heard me, looked up and said, ‘What part of the Island are you from?’ ”

“Why nursing?” I ask.

“I had a scholarship to the American Ballet Theatre, and I was good, but I wasn’t brilliant…and my dad said, ‘You need an education—go be a nurse.’ ”

I can’t imagine Melissa in ballet shoes, but 29 years ago, she traded them for a stethoscope. We’re at Orso, across the street from Cedars, having dinner after Melissa’s 7 a.m.–to–7 p.m. shift. She’s wearing a chic black jacket over blue scrubs, but there are smudges under her eyes. “Where do you find joy in the job?” I ask.

Without blinking, she says, “Using my knowledge to participate in stopping bad things that happen to people.”

Of course, they can’t always be stopped. You can’t stop a mother’s pain when her 18-month-old drowns. “The mom was still wet,” she says, “making a puddle by room three. When she knew her baby was gone, she wailed…just melted to the floor.” She pauses. “I swaddled her in warm blankets. It was all I could do for her.”

“What do you do for you?”

“I compartmentalize,” she says, finally smiling. “And I buy very expensive shoes.” She must have a closet full of Manolos.

Shari runs to cope with the stress. She did the 2007 Boston Marathon. “I’ve also run after psych patients who escaped the ER and took off down Gracie Allen toward 3rd Street.” She works mostly as a charge nurse, overseeing patient flow. If paramedics bring you in on a gurney, you’ll see the charge nurse first. That’s who decides whether the man in room four gets kicked into the hall because the room is needed for the woman the LAFD just scooped up off the pavement.

Some ER nurses charge, but all work triage and patient care. There are approximately 15 nurses on each shift, and shifts change all day. There are 41 beds in the ER—58 if they fill the halls. Cedars is a number one trauma center—the wait can be 10 minutes or four hours. Think of all the L.A. hospitals that have closed.

Shari, who was raised on a farm in Racine, Wisconsin, has been a nurse for 21 years. The only other job she considered was a baker…and that was when she was five. “How come you didn’t do that?”

“They have to get up really early,” she says, taking a bite from her perfectly wrapped homemade sandwich. She expertly cuts her peach with a paring knife.

Shari came on at 11 a.m. and will work until 11 p.m. We’re in the cafeteria on her dinner break, but she looks like she has just showered—blond curls escaping a perfect ponytail—a Goldilocks nurse who behaves like a general. I have seen her hustle a parade of bloody, broken patients through the door with the cool calm of an air-traffic controller moving jets through a bank of thunderstorms.

Abby and Sylvia carpool from Santa Clarita. They call the drive back and forth to Cedars their “psychotherapy hour.” Abby, fast and funny, was born in the Philippines. She has been a nurse 27 years—Hoboken and then L.A. “Why nursing?” I ask.

“I got into the short line,” Abby says, and she and Sylvia fall into a fit of laughter. “I’m Chinese, and when you’re Chinese, you’re supposed to study math—go into accounting, banking. So I went with my girlfriends to apply to school. All of the lines were really long, but there was this one short line, so I got into that one.”

“It was the premed, premed tech and nursing line,” Sylvia adds, smiling widely.

“I passed the test,” Abby says, “and I said to my friends, ‘Nursing?! My mom is going to kill me.’ ”

The ER can bring out the worst in people—not just the patients but the people bringing in the patients. Week after week, I see fear breed anger and despicable manners. I ask Abby how she deals with that. “You can’t take it personally,” she says. “You have to get over it and move on.”

“What’s the joy in this job?” I ask Sylvia, who has three children and has been a Cedars nurse for 19 years—not long enough to dim her radiant smile.

“You get to help people,” she says. “You make a difference.”

The nurses remind me about the funny stuff: the toddler whose potty got stuck on her head when she tried to put it on like a hat; the four-year-old who shoved an aspirin up his nose. “Did you have a headache?” Rich asked the kid.

Some of the nurses are on their second careers. Paul, one of the calmest in the ER, was a Navy SEAL. Jerry, who could find a vein in a stone, was a fashion designer. Joe was in marketing at Anheuser Busch. “And then came 9-11,” he recalls, “and I was watching those firefighters on TV, and I just knew I had to change my life. I had to do something honorable.”

Clean-cut, in pressed scrubs and Clark Kent glasses, Joe is the one you’d want to marry your daughter. “Can you have the same compassion for a drug addict as you do for a cardiac arrest or the patient back for the third time with terminal cancer?” I ask.

“You have to. What about the guy booked on a double vehicular manslaughter, still drunk, spewing ef-yous and showing no remorse? He’d kept driving after he hit them,” Joe says, eyes narrowing. “You have to give him the same care.”

Lots of people are brought into the ER in cuffs—think of gang shootings, car wrecks, domestic violence. Bad guys get hurt just like good guys, and they’re all brought to the same ER.

Kelly wanted to be a cop. “First an actress, second a cop,” she says. Raised in Tennessee and Arkansas, she calls herself a hillbilly but looks like a movie star. She hunts, motorcycles, parachutes and has an 11-year-old son. A nurse for 10 years, she once did CPR on a woman in the ER driveway.

“I was triaging, the doors opened, and someone was yelling for help. It was the sound of the help; the hairs on the back of my neck stood up,” Kelly recalls. “Female, mid seventies, cold as a cucumber, not breathing, in the passenger seat. I pulled her down onto the cement. There wasn’t any time; her feet were still in the car.”

Flor nods. She, Kelly and I are at Du-par’s on their day off. “I did CPR on a doctor once,” she says. “We were moving him to the OR, and he went into cardiac arrest. I jumped up on the gurney, straddled him and did CPR—in the elevator. It probably didn’t look good,” she says, brown eyes wide.

Flor is a “good Catholic girl” from Manila—nuns and rosary beads to Kelly’s bikes and rifles. “My aunt was a nurse in the U.S., and when she’d come home, it was like she was a celebrity. People gathered around—they made a fiesta: We have to kill a pig,” she says, grinning. “They respected her, and I thought, I want to be like that.” She has been a nurse for 31 years. She has three kids in college and looks like she’s their age. “I’m a caregiver,” she says. “That’s what I took the oath for.”

Triage is the hardest, most ER nurses agree. It’s not just the patients’ vitals. What are the skin signs, the alertness, the level of consciousness? Sweaty, pale, faint, red? It’s not just their pain.

“Triage is the most dangerous,” Nili says.

“You use your clinical judgment to assess the patient. You can’t let anyone slip past you, and you can’t make a mistake.” Tall and impressive, if Nili walked into your room with a needle, you’d extend your arm. “Why did you go into nursing?” I ask.

“Oh,” she says shyly, “I was out of control at Cal State Northridge, and my parents said, ‘It’s either nursing school or leave home.’ ” She has been on the job for 16 years. “Not everyone can do it.”

Well, that’s for damn sure. I’ve seen Nili on the trauma team, suited up in blue plastic, waiting for the paramedics to arrive, like a solider about to take a hill. I’ve sat next to her at the radio when the LAFD calls. The silent blue lights in the corners of the ER flash and spin, and a nurse on the blue team hotfoots it to the radio room. “Cedars base, copy,” and the line crackles: “This is Rescue 41. I have a 57-year-old male, altered LOC, in moderate distress; this is Rescue 27, I have a 16-year-old female…” And on it goes.

“Every day is a crisis,” Nili says.

ER nurses don’t give long-term care. They don’t get to know you, and they don’t even know what happens to you after you leave the ER. They are a platoon of adrenaline junkies with invisible capes and angel wings, there to take care of you at your worst moments. And it never ends. “Patients are like waves of ocean hitting the beach,” Shari says. “New ones just replace the old ones.”

“If I have to cry, I cry,” Mark says. “You can’t carry it to the next shift.” Blond and lanky, he has the mischievous air of a reformed bad boy. He did 10 years as a paramedic before his 10 as a nurse, so he has seen his share. “I wanted to be that person who knew what to do, how to run a code—perfectly.” A code, even laypeople know, is when the heart stops.

Mark thinks about the process for a moment and flashes one of his rare smiles. “It can be a miracle,” he says.

“Does it scare you anymore?”

“No,” he says. “I’m either enlightened or f–ked up.”

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Love Binds Doctors to their Patients in a Unique Way

Truth in the Cathedral of Medicine

Leap, Edwin MD

Dr. Leap is a member of Blue Ridge Emergency Physicians, an emergency physician at Oconee Memorial Hospital in Seneca, SC, and an op-ed columnist for the Greenville News. He welcomes comments about his observations, and readers may write to him at emn@lww.com and visit his web site and blog at www.edwinleap.com.

When this is published, we could be on our way to a new health care system. I don’t know what that will entail. Few in the government really want my opinion. That’s the way it is; we have limited power. Or do we?

Last night at work, I diagnosed a man near my age with new onset diabetes and osteomyelitis of the toe. He was terrified, and fear radiated from his face. He was afraid of diabetes, of neuropathy, of amputation.

We talked a while as I dealt with his blood glucose, then admitted him to the hospital for a surgeon to evaluate his foot and a hospitalist to control his diabetes. He thanked me for smiling and being kind. We shook hands and laughed before he went upstairs into his diabetic future. He felt better. He felt that someone cared for his situation.

Reform or not, the one thing we can do as physicians is just that. We can be competent and compassionate. We can smile and touch. We can do the right thing as long as government lets us. (Pay attention to that thought: as long as they let us. Store it away, and watch the future unfold.)

I have been told by some that government-run health care would be better than industry-driven health care. I have been told the opposite as well. Each side makes the argument that it will have greater accountability to the sick. Advocates for government suggest that we as citizens can hold them to more rigid standards, can get what we want and need more effectively through the legislative process. Those for the market believe that profit will always do a better job of driving customer satisfaction, efficiency, and lower costs, that profit and shareholder interests will make the market a better choice.

I have an idea about that. The only direct accountability any patient can ultimately exercise is between caregiver and patient. You can argue on the phone for weeks, and never speak to the right person at an insurance company. They can delay and evade for months. You can call your favorite government functionary who works behind a shield of anonymity and distance, guarded by layers of voice-prompts on telephones. None of them is accountable the way we providers are.

And so, we have power. We can do what I did with my diabetic friend. We can touch and smile. We can care. We can do the right thing as much as possible. We can show compassion, live compassion, feel compassion. We entered medicine because we genuinely cared about the sick, the dying, and the broken. Our best hope for the future of medicine is to continue to do the same, or if lost, to rediscover what was driven from our hearts.

Our proximity to the sick is an advantage no one else possesses, and in truth, that no one else desires. Our love for them is the most powerful weapon we have as we try to reform.

I don’t know what the future holds. I hope it holds continued jobs, continued freedom and choice, continued competence in medicine. I hope it involves amazing innovations and improvements in quality of life.

But whatever it holds, good or bad, I do know the way to safeguard our place in the process as physicians, nurses, and other health care providers. The solution for caregivers is, ironically, to give care! If we give care, if we give love and concern, if we give of ourselves to those suffering, we will have far more power than any government functionary or insurance company voice on the phone.

We may have our payments cut, our influence squashed, our opinions silenced. But our compassion will continue to connect us, our love will continue to rebuild the broken and to speak with a thunder no government or corporation can match.

Maybe, in the end, we can reassume control of health care. And why not? We know it better than anyone else; we know the sick better than anyone. We touch them, treat them, listen to them, and even see them leave this life. Those are powerful qualifications for leadership.

But we’ll never have control, ever again, if we give up the one velvet weapon we have, which is love for those charged to our care. For faith, hope and love abide these three, but the greatest of these is love. And it’s never more true than in the cathedral of medicine.

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Healthcare Reform: Finally a concise & accurate article

I have been reading all the articles about the healthcare issue in the New England Journal of Medicine–medicines premier journal.

I have been disappointed by the wordiness, political biases, and inaccuracies of the articles in the NEJM.  I have finally come across a concise & accurate article:

Health Care Reform and Clinical Culture

It is a tired and cynical cadre of physicians who will implement health care reforms. Yet few published perspectives include the view from the factory floor. The usual platitudes about changing financial incentives, increasing efficiency, and delivering high-quality care sound naïve to clinicians who deal with the imperfections of human nature and the messy effects of illness on patients. Doctors are already, by training, sophisticateddecision-making machines, capable of achieving extreme efficiency through the use of heuristics and experience.The main problems that clinicians face in achieving efficiency and reducing costs are, first, a perceived need for certainty in diagnosis and treatment — a need driven by secular expectations and malpractice concerns; second, gross inefficiency created by obligatory documentation to satisfy billing requirements that have little value for clinical care; and third, restrictions on the use of clinical judgment that could avoid excessive testing. None of these problems, whose solutions would save money and time, have been incorporated into the national discussion about reform.

One change that would augment the role of clinical judgment would be for the health care system to resist the temptation to require adoption of often-elusive “best practices.” Therehas been an assumption by analysts that published clinical trials provide a sound guide for therapy, but all reputable studies report odds, hazard ratios, and effect sizes, almost all ofwhich are small or modest. Absolutes are discordant with the realities of sickness and health. There may be guidelines and measurable outcomes for mundane problems, but for the vast majority of daily doctor’s visits and hospital decisions, incremental or recursive approaches to diagnosis and treatment are more effective and efficient.

A second reform should be to limit malpractice awards so as to reduce physicians’ fear of lawsuits. Regardless of the arguments of defenders of open-ended malpractice payments, this insidious concern is a major driver of overtesting and overconsulting.

A third key reform would be to eliminate the time sink of the comprehensive exam and its lengthy documentation required by Medicare — a requirement that is likely to be adopted or exaggerated in any new codified system. Immaterial information is already cluttering the electronic medical record. My survey of neurology notes, which I presume would be among the most thoughtful in medicine, shows that less than one fifth of the average note is taken up with analysis and discussion of the patient’s problem; the remainder is part of the “waste” in modern medical care.

Fourth, payment codes should be reduced to “simple” and “complex” — or at least the numerous billing levels and codes should be conflated, and payment should be based on diagnosis and time expended. Physicians should also be paid for their expertise.

Health care reform can redress slowly accrued and detrimental cultural changes, particularly the loss of reliance on clinical judgment. It would be a missed opportunity if practicing physicians (as contrasted to their representative bodies and societies) were excluded from the center of the conversation. The efficient use of the professional workforce will be more powerful than rules.
Allan H. Ropper, M.D.
Brigham and Women’s Hospital
Boston, MA

This article (10.1056/NEJMopv0907607) was published on August 26, 2009, at NEJM.org.

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Healthcare Debate: Malpractice Reform

3rd and final article from Emergency Physicians Monthly…saved the best for last.  This is the single most important issue in all of the physicians minds that I have spoken with, but of course, no one in politics has addressed it. I wonder why? Hmmm…

Just A Spoonful of Reform Print E-mail
by Greg Henry, MD

These are clearly the times that try men’s souls, or at least their patience. As health care reform is being contemplated throughout the country, there are more and more chances that we’ll get it wrong as opposed to getting it right. However, disagreements aside, emergency physicians need to come together and decide what goals we will put forward. We need to stop wasting time asking whose name is on the bill and start asking if the policies will meet the long-term goals of our specialty. There are many policy areas where emergency physicians need to get involved, from services rendered to workforce issue, but let’s begin with the medical-legal structure since we are most likely to get some unanimity in this area. I’ll give some ideas that I think are straightforward and could be a win-win situation for the government.

Ever since the passage of EMTALA, emergency physicians have been de facto employees of the federal government. We don’t get to decide whom we see. We have no way of deciding who walks in the door or whether we’re ever going to see a dime for the services rendered. We also have no way of knowing if those patients, who may not even pay the bill, are going to sue us. I think that there are multiple things that can be done right now with the Obama administration to address this issue.

The first thing is to agree that rendering care to those in need is not the problem. One of my greatest badges of honor is the ability to say that I have never denied anyone health care based on their ability to pay. We are the physicians who carry the staff of Asclepius the highest. We are the ones who, any moment of the day and night, see anyone and give out health care. This is part of who we are and should not change. But give me a break! This ought to be recognized and rewarded in at least two ways. First, emergency physicians should be able to calculate the value of the free care they were mandated to give out in a given year and then deduct some portion of that amount from their income taxes. If, in a year, I give out $160,000 of free care – which I’m perfectly happy to do – the government ought to be perfectly happy to let me at least write the loss off on my taxes. What’s wrong with this idea? I understand that this would reduce the income coming to the government, but if they actually had to pay for that same care, it would cost even more.  The federal government needs to recognize that emergency physicians are acting as conscripted government workers and should receive some sort of compensation.  Don’t give me 100%. No insurance company gives me 100% (and ever since California cancelled balanced billing none of us will ever again expect to see 100% of charges) but don’t let me drown in red ink! The logic is straightforward. As tax-paying citizens, we do not expect Boeing to make planes for the U.S. government and not get paid for it. Why would we expect physicians to give out health care and not get paid?

Second, there is no reason for EPs to bear the liability of every patient who walks into the emergency department. We need to have some reasonable liability relief. I believe that since we have essentially been named the de facto employees of the federal government, we should be covered by the federal government like any other federal employee. If the mailman runs over your mailbox, the government handles that liability. The concept is called “respondeat superior,” or “let the master answer.” Well since our master, the federal government, has decided what we will do and what we will get, let him also be involved in the malpractice issue. For physicians of any specialty who are mandated by law to see ED patients, liability should be handled through a no-fault system paid for by the federal government. In some states, this might mean as much as $40,000 savings in insurance costs. Having a federal system that would, without fear or favor, use a no-fault system to evaluate harm and properly compensate patients who are truly damaged, would work out for the benefit of physicians and patients alike.

And finally, it has been estimated that less than 15% of the funds that go into malpractice insurance policies actually wind up in the pockets of patients. Most reasonable physicians could look at a situation and decide whether a patient was truly harmed by the actions of other physicians. So be it. But do not let 40% of the money go directly into the pockets of attorneys. Both plaintiff and defense attorneys strip us down for money. Do not let people who are on the fringes of health care continuously drain the pockets of emergency physicians. It just doesn’t make sense. A simple act of assuming liability and creating boards which look at the extent of injuries would go a long way towards lowering health care costs, making physicians more comfortable with their clinical decision-making and stopping the mindless ordering of tests which are part of the “cover-your-ass” medicine which supposedly protects us from lawsuits. These few simple actions could be just the teaspoon of sugar needed to help the bitter pill of health care reform go down smoothly.

Greg Henry, MD, is the founder and CEO of Medical Practice Risk Assessment, Inc. Dr. Henry is a past president of ACEP and directed an ED for 21 years.
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Healthcare Debate: The Kennedy/Dodd Bill

This is the 2nd article of 3 from Emergency Physicians Monthly on healthcare reform issue.

Please also see the GREAT comments to this important article.

The Kennedy/Dodd Bill: A Physician’s Analysis
The Senate Health, Education, Labor, and Pensions Committee, chaired by Sen. Chris Dodd (D-Conn), passed a health bill on July 15th that finally laid out the specifics of the biggest overhaul of health care in history. You can read a staff draft of the bill HERE (text file). Here are the highlights.
by Mark Plaster, MD
Executive Editor
First, everybody has to be in a “qualified plan” as defined by the Secretary of Health and Human Services. If you can’t prove that you have been insured for every month of the last year, you’ll be assessed a surtax to cover the government covering you. Of course, if you don’t pay taxes, as an increasing number of people don’t, it won’t effect you. If you are an employer, you have to pay a minimum percent or dollar amount of the premium for the plan, but only if you don’t already offer insurance to your employees. If you do, and the plan is ‘qualified’, then you don’t pay the surtax. And how much is the tax? Whatever the Sec of HHS deems is necessary to get everyone to participate.

But what defines a “qualified plan”? The Kennedy bill mandates guaranteed issue and renewal. Everybody can get insurance and nobody can be canceled, regardless of your past health or your lifestyle choices. The plans could not charge more for people who engage in increased risk lifestyles or habits, such as alcoholism, drug addiction, obesity, etc. Each qualified plan must have a modified community rating to pay more to areas of the country where medicine costs more. There can be no caps on annual or lifetime benefits. And family policies must cover ‘children’ up to age 26. Qualified plans must have at least three levels of cost sharing, cover a list of preventive services approved by the government and cover “essential health benefits,” as defined by the new Medical Advisory Council (MAC), who would be appointed by the Secretary of Health and Human Services. The MAC would have control over such services as out patient care, emergency services, all hospitalization, maternity care, mental health, pharmaceuticals, rehab, and any other services that it deemed essential to health. The MAC would also define what was “affordable and available coverage” for different income levels.

The Kennedy bill would expand Medicaid to cover everyone up to 150% of the poverty level, with the federal government paying for all the increased costs to the states. People making between 150% and 500% of the poverty level would be subsidized by the government on a sliding scale. To put that in perspective, a family of four making $110,000 would still get a small subsidy. People living in big cities would get larger subsidies. Of course, this Committee has no ability to write actual tax law to fund this legislation. That’s up to the finance committee.
The largest of all the hurdles in the bill is the “public plan option,” in which the government will offer to include people in Medicare. To sweeten the offer, the legislation calls for physicians to be paid at Medicare rates plus 10%. The legislation makes no mention of the future payments. Nor does it acknowledge that the Sustainable Growth Rate calculations for physician reimbursement from Medicare are currently calling for a 21% cut in compensation. Group health plans with 250 or fewer members would be prohibited from self-insuring, leaving ERISA to big businesses.
The legislation calls for health insurance to be sold through “gateways” set up by state governments that market only “qualified plans.” These “gateways” would have “navigators”, also paid by the state, the enroll people. The organizations receiving these funds could be community organizer groups or unions.
As previously stated, an interesting loophole exists in this bill that would exempt health insurance plans that met the standards of a “qualified plan” that were in existence before the legislation. The effect of this could make it very difficult to change jobs, if the new job was paying the higher cost of mandated insurance.
Another huge hurdle is the definition of who must get insurance. The bill defines an “eligible individual” as “a citizen or national of the United States or an alien lawfully admitted to the United States for permanent residence or an alien lawfully present in the United States.” This appears to open the door to medical coverage to every illegal alien who is granted some type of amnesty.
The only hope for controlling costs in this bill is the re-introduction of the gatekeeper concept that was tried 20+ years ago. Under this scheme, the gatekeeper, called a “medical home”, is a patient’s private practitioner would have the control of whether a specialty referral was made, tests were ordered, or hospitalization occurred. He would have 10% of his compensation held back each year until it was known whether he met the limits on spending on each patient. If he failed to meet the spending goals for each patient, he would have to pay for the care from his own pocket.
What are the potential effects of the Kennedy-Dodd bill, should it pass? First is the price tag. Those who pay most of the tax revenues of the country would see their taxes rise significantly. Businesses will have to incorporate these increased costs by lowering wages, hiring fewer people, or moving to other areas of the globe. Small business could be hardest hit, though there is talk of a small business exemption. But it is unlikely that tax increases on the upper income taxpayers would be enough. President Obama has already started to reverse his campaign pledge that those making less that $250,000 “would not see [your] income tax rise one penny.” He is now admitting that medical benefits would need to be taxed. So if someone making $80,000 per year was receiving a $10,000 per health plan, he would be taxed on $90,000, thereby increasing his taxes up to $2,000 without any increase in salary.
The biggest effect would be 50 million new patients. With the current saturation of many private physician practices, many of those patients would come to the ED.  Convincing gatekeepers to refer and specialists to accept these patients could get significantly more difficult, exacerbating wait times and holds.
Another huge effect would be the power of the Medical Advisory Committee. Unelected, virtually unsupervised individuals would control what health care looked like in this country, who was covered, who paid, and what services were covered at what compensation.
Cost shifting from the healthy to the unhealthy and those who engage in risky lifestyles would increase dramatically. The only control of this would be through lobbying the members of the MAC.
And finally, this bill would not effect members of Congress despite Mr. Obama’s campaign promise to offer Americans “the same kind of coverage that members of Congress give themselves.”
Mark Plaster, MD, is the Executive Editor of Emergency Physicians Monthly
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Healthcare Debate: The Wrong Questions

This the 1st of 3 brief articles written by physicians regarding their concerns with healthcare reform:

“The Wrong Question” Print
by Mark Plaster, MD

I sat transfixed reading the email from a friend. I couldn’t believe what I was reading. Finally my wife broke into my thoughts. “What are you doing? I’ve been calling you for ten minutes. And when I find you, you’re staring at the computer, shaking your head and mumbling.”

“I can’t believe what I’m reading,” I mumbled. “This health care debate has turned everything on its head.”

“What ARE you talking about?”

“You know that story I used to tell about calling that lazy urologist up late one night? I asked for his help to cath a patient with a stricture and he says, ‘How old’s the patient?’. When I tell him the patient’s 81, he just growls “He’s peed enough,” and slams down the phone. Do you remember that story?”

“Yes,” she said with a scowl. “I hate that story.”

“Well, that seems to be the new strategy for reducing the cost of health care while extending it to the uninsured. This article that David sent me is about a guy who feels guilty for getting treated for his prostate cancer.”

“I don’t get it.”

“Yeah, he says maybe he should’ve just died and saved the money for the system.”

“That’s kind of twisted,” she said with a shrug. “I can maybe see someone deciding to forgo treatment if there isn’t any hope of recovery.”

“That’s OK if you are deciding for yourself. But this guy got his treatment. He has a good chance of full recovery. And now he’s trying to guilt other people into forgoing treatment in the interest of saving money.”

“Just for the sake of argument . . . ” she started.

“I can always depend on you to be the devils advocate. I can see you starting to sprout horns already.”

“No, seriously,” she said, “haven’t you always said that people spend more in the last year of life than in all the other years combined? Couldn’t the system save a lot by foregoing a lot of needless treatment?”

“Who says it’s needless? You never really know if a treatment is going to work. What doesn’t work for one person might work just fine for you. I don’t want anybody making that decision for my life, but me.”

“But what if you are too senile to make that decision,” she said, starting to warm to the debate. “You wouldn’t want us to spend everything we had on every unproven treatment, would you?”

“I will concede that we shouldn’t be using insurance money to pay for treatments that have not been shown to work. But if I’ve been paying into the system all my life, shouldn’t I get a chance to try some experimental treatments?”

“Well . . . ”

“And I hate it when you throw the ‘senile’ thing at me.” I furrowed my brow and gave her a suspicious pout. “There’s nothing wrong with a little senility.”

“Oh, come on. You don’t want to just sit around in a nursing home and drool like that lady you used to tell me about, the one you had to change a diaper for all the time.”

“The lady you’re talking about was named Gladys and she seemed perfectly content to smile, drool, and poop in her diaper. Like I said, there’s nothing wrong with a little senility. The fact is that I’m sort of looking forward to a little dementia. I want to live with one of our kids when I get senile. It will pay them back for all the years that I changed their diapers.”

“When did you ever change a diaper?” she snapped back.

“Do you remember that time that we were…you know…having a little roll in the sack and one the babies started crying. And you ran in and brought him to our bed and he threw up on me. Do you remember that? Talk about ruining the moment.”

“Talk about holding a grudge,” she said shaking her head.

“I can still feel the sensation of baby vomit running down my bare legs. I spent the rest of the night picking chunks of beets out of my chest hair.”

“That made quite and impression, didn’t it?”

“It’s a nightmare I’ll never forget,” I said, mocking her mocking me. “I’m just saying that we took care of the kids when they were babies. Why shouldn’t they take care of us when we are old.”

“OK,” she replied slowly. “But you lost me on how this relates to the health care reform debate.”

“Don’t you see? The whole debate is turning things upside down. People who haven’t paid anything into the system are claiming that they have a right to healthcare. And people who have been paying into the system for years are being guilted into refusing to take what is rightfully owed to them. The throw-up story was just a colorful aside.”

“But you’re not denying that we spend a disproportionate amount of the total health care expenditure of the country on the elderly?” she said trying to score a minor victory.

“OK, maybe we do a little. But all kidding aside. Every day of every life is valuable. And we shouldn’t be pitting one group against another in an effort to balance the health care budget. It’s not a zero sum game.”

“Well, one thing’s for sure. The country can’t continue to spend more and more on health care.”

“Do you hear what you’re saying? You’re beginning to sound just like all those bureaucrats in Washington. People should be able to spend their money on whatever is important to them. It’s pooled insurance money, or worse, government insurance money, that has people thinking that how they spend their health care dollar is the business of other people.”

“So you would like to see us go back to a purely free enterprise medical system? First, that’s not going to happen. This isn’t the 50’s. And second, what would happen to the people who don’t have enough to pay for expensive medical care. I know that you can be a cold, heartless, S.O…”

“Hey, don’t start talking about lawyers again.”

“… but I don’t think you are advocating cutting people out of the system.”

“Of course not,” I said, becoming serious again. “There’s more than enough excess in the system to pay for truly needed medical care for everyone. And if you want something that has marginal value, you should be able to get it. But you should have to pay for it. If you can’t afford something that has marginal value, then you shouldn’t get it. It’s that simple.”

“It’s that simple, huh? You seem to have it all figured out. So why is Congress having such a tough time with this?”

“They’re asking the wrong questions. And they are pitting one group against another, like they always do.”

“There’s just one question remaining, smarty pants. Who is going to decide what is ‘truly needed medical care’?”

“We are,” I said confidently. “Physicians are the only ones who can make that decision. All we need are education and ethics. The basics. And we need protection from the lawyers when we have to make a close call or when a bad outcome occurs.”

“Now you’re the one talking about lawyers.”
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Promising the Impossible

The OC Register had a concise and important editorial in today’s newspaper regarding the healthcare issues.  As always please share your thoughts with us.

Promising the impossible

Reformers’ health care promises not worth a wooden nickel.

John Stossel

John Stossel
Syndicated columnist,
Co-anchor of ABC News’ “20/20”

I keep reading about health-care “reform,” but I have yet to see anyone explain how the government can make it easier for more people to obtain medical services, control the already exploding cost of those services and not interfere with people’s most intimate decisions.

You don’t need to be a Ph.D. in economics to understand that government cannot do all three things. (Judging by what Paul Krugman writes (http://tinyurl.com/lgpr4o), a Ph.D. may be an obstacle.)

The New York Times describes a key part of the House bill: “Lawmakers of both parties agree on the need to rein in private insurance companies by banning underwriting practices that have prevented millions of Americans from obtaining affordable insurance. Insurers would, for example, have to accept all applicants and could not charge higher premiums because of a person’s medical history or current illness” (http://tinyurl.com/knzczq).

No more evil “cherry-picking.” No more “discrimination against the sick. But that’s not insurance. Insurance is the pooling of resources to cover the cost of a possible but by no means certain misfortune befalling a given individual. Government-subsidized coverage for people already sick is welfare. We can debate whether this is good, but let’s discuss it honestly. Calling welfare “insurance” muddies thinking.

Such “reform” must increase the demand for medical services. That will lead to higher prices. Obama tells us that reform will lower costs. But how do you control costs while boosting demand?

The reformers make vague promises about covering the increased demand by cutting other costs. We should know by now that such promises aren’t worth a wooden nickel. The savings never materialize.

Some of the savings are supposed to come from Medicare. The Times reports “Lawmakers also agree on proposals to squeeze hundreds of billions of dollars out of Medicare by reducing the growth of payments to hospitals and many other health care providers.”

With the collapse of the socialist countries, we ought to understand that bureaucrats cannot competently set prices. When they pay too little, costs are covertly shifted to others, or services dry up. When they pay too much, scarce resources are diverted from other important uses and people must go without needed goods. Only markets can assure that people have reasonable access to resources according to each individual’s priorities.

Assume Medicare reimbursements are cut. When retirees begin to feel the effects, AARP will scream bloody murder. The elderly vote in large numbers, and their powerful lobbyists will be listened to.

The government will then give up that strategy and turn to what the Reagan administration called “revenue enhancement”: higher taxes on the “rich.” When that fails, because there aren’t enough rich to soak, the politicians will soak the middle class. When that fails, they will turn to more borrowing. The Fed will print more money, and we’ll have more inflation. Everyone will be poorer.

The Times story adds: “They are committed to rewarding high-quality care, by paying for the value, rather than the volume, of [Medicare]services.”

Value to whom? When someone buys a service in the market, that indicates he values it more than what he gives up for it. But when the taxpayers subsidize the buyer, the link between benefit and cost is broken. Market discipline disappears.

Listening to the health-care debate, I hear Republicans and Democrats saying it’s wrong to deny anyone anything. That head-in-the-sand attitude is why Medicare has a $36-trillion unfunded liability (http://tinyurl.com/72bm5h). It’s not sustainable – and they know it.

They’ve given us a system that now can be saved only if bureaucrats limit coverage by second-guessing retirees’ decisions. Government will decide which Medicare services have value and which do not. Retirees may have a different opinion.

One may be willing to give up the last year of life if he’s in pain and has little hope for recovery. Another may want to fight to the end. But when taxpayers pay, the state will make one choice for all retirees.

Now, to reduce the financial burden of the medical system, Obama proposes a plan that inevitably will extend the second-guessing to the rest of us. So much for his promise not to interfere with our medical decisions.