Black Dog Thoughts on Black Friday

Today is Black Friday, the day after Thanksgiving.

For me it is a day of black thoughts on health reform, perhaps because I’ve been reading about Winston Churchill as seen through the eyes of his physician, Lord Moran. Churchill was subject to attacks of the Black Dog, bouts of depression. One black dog came in 1945, after Clement Attlee and the Socialists defeated him and the Tories. Churchill could not believe the English people turned him out after he had led England to victory after World War II.

Churchill did not believe in socialism - government policies dictating takeovers of private industries, wealth redistribution, and standardization, homogeneity, and uniformity of health care for all with equal benefits for all.

Socialism is utopianism, but it has flaws. So does capitalism. As Churchill so famously said, “The inherent vice of capitalism is the unequal sharing of blessings, the inherent vice of socialism is the equal sharing of miseries.”

This quote got me to thinking about problems of how one can standardize, homogenize, and make uniform the behavior of physicians, a notoriously independent lot who believe their clinical judgments surpass that of government or any clinical algorithm, protocol, or guideline. Perhaps one can erase regional and personal differences in care, but I am dubious.

The first problem is that government officials are not present at the site of the doctor-patient encounter. Remote bureaucrats, no matter how smart, cannot construct protocols covering every possible permutation and combination of clinical encounters subject to the whims of human behavior.

A second problem is that doctors, like patients, are infinitely variable. As a health care Pied Piper might say, doctors come in all varieties. There are big doctors, small doctors, lean doctors, brawny doctors, fat doctors, male doctors, female doctors, brown doctors, black doctors, white doctors, grave old plodders, gay young friskers, aggressive doctors, passive doctors, compulsive doctors, intuitive doctors, procedural doctors, cognitive doctors, entrepreneurial doctors, health system doctors, doctors that practice in bewilderingly different settings, each requiring different mindsets and skills.

To complicate matters further, there are solo and two practice doctors (47%), doctors in groups of 3-5 (15%), groups of 6-50 (32%), doctors in hospitals (13%), doctors in medical schools (7%). Doctors in groups of more than 50 (6%), doctors who work in HMOs (4%), and doctors who slave in community health clinics (3%)- each with different mindsets and views of the world. It becomes almost impossible to design an information system that fits them all, pleases them all, and ties them altogether.

It would make socialistic and managerial sense to herd all doctors into large groups or institutional settings that are "integrated" and "coordinated". That way you could put those free-thinking doctors on salary and make them follow rules of the organization and/or government mandates. It would make sense, too, I suppose, to stop all fee-for-service payments, the mode of reimbursement for most other professionals that invites over-use and rests of trust.

A third problem, and it's a whopper, is that America is a center-right individualist. freedom-loving nation that does not believe in centralized, collectivized government. Give me freedom, choice, and opportunity are our rallying cries.

A fourth problem, another whopper, is constructing a giant fail-safe bureaucracy with rules, regulations, protocols, and guidelines to cover every clinical eventualities and different physicians and patients personality types.

To do so, you would have to make myriads of payment, insurance, government changes, experimental demonstration programs to test your changes, and different government agencies to make sure the changes worked in real world. Given the infinite variety of human beings and their needs and vagaries, this new health system might look like this.

>YOUR NEW HEALTH CARE SYSTEM

PRESIDENT

INTERNAL REVENUE SERVICE

CONGRESS

SECRETARY OF HEALTH AND HUMAN SERVICES

ADMINISTRATOR OF CENTER OF MEDICARE AND MEDICAID SERVICES

NATIONAL COORDINATOR OF INFORMATION TECHNOLOGIES

NEW INSURANCE PROVISIONS, ADMINISTERED BY GOVERNMENT EXPERTS

NEW MEDICARE /PAYMENT PROVISIONS, ADVANCED BY ANOTHER SET OF TECHNOCRATS

NEW DEMONSTRATION/PILOT PROJECTS AND ADDITIONAL PROVISIONS, TOO NUMEROUS TO MENTION

NEW AGENCIES

• CENTERS OF MEDICARE AND MEDICAID INNOVATION

• INDEPENDENT MEDICAL ADVISORY BOARD

• PATIENT-CENTERED OUTCOME RESEARCH INSTITUTE


Patients - Doctors


Please note: Patients and doctors are in small print at the bottom of the bureaucratic pile. Wedged and buffered between them are, at last count, 159 different government agencies, boards, and panels. And that doesn’t count tens of thousands of government employees and 13,500 IRS agents required to implement and enforce the whole bundle and caboodle. Regulatory interpretations are piling up, along with regulatory burdens. Since ObamaCare and the Reconciliation Act were signed into law in March, there have been no fewer than twelve sets of additional regulations, guidelines, or notices that have been issued to lend clarification and at the same time add additional regulatory requirements.