Tectonic Movements  and The End of Obamacare

Tectonic – Referring or pertaining to forces or conditions inside the earth that cause movements or the crust, as earthquakes, folds, faults, and the like.

I’ve been reading a book by a noted historian, John Lewis Gaddis, The United States and the End of the Cold War (Oxford University Press, 1992).  In chapter nine, “Tectonics, History, and the End of the Cold War,” Gaddis explains that changes in the physical and political world can change abruptly. “Conditions can persist for years with little attention, only to have them disappear – to the astonishment of almost everyone – almost overnight.” This, he says, is due to underlying political and economic trends, not unlike geological fault lines.

What are these fault lines, that ended communism,  and do they apply to Obamacare? According to Gaddis, the pollitcal and economic fault lines are:

·         One, new criteria for power.   In the case of the cold war, it became obvious that economic progress and centralized planning did not  mesh.   At this stage, Obamacare smacks of centralized planning, but whether the U.S. is making economic progress is still up debate. All we know is that economic growth is about half what is has been in irecoveries from previous recessions. One of the new criteria for power is economic growth or lack of it.
 

·         Two, collapse of authoritarianism – Here Gaddis argues government cannot force citizens to produce goods and services according to a central plan.  Central planners simply  cannot respond fast enough to shifts of supply and demand, to satisfy most of the population.  Only self-regulating markets can do that.   With Obamacare,  it seems improbable that it will have health exchanges up and running by October 1, 2013 and whether enough people will sign up for exchanges to make them worthwhile.  The government does not yet have the computer capability to handle the load that individuals that may sign up and flow of information will demand.  Whether the series of “mandates” in the law or the IRS  for 20,000 new IRS agents and an unprecedented expansion of the IRS computer system will cause authoritarianism to collapse remains to be seen. That may depend on the outcome of the IRS "scandal." Another question is: will the health system collapse if Obamacare collapses? I doubt it.

·         Three, the Decline of Brutality – Brutality among totalitarian regimes no lomnger works. This may be due to openess and transaprency engendered by the Internte and the social media. Secretness and behind the scenes political maniupulations  no longer works  well in the Internet age.  Anyway, Obamacare is not communism nor socialism for the matter. It is anti-colonolism,  Brutality is not part of the Obamacare agenda,  unless one deems IRS targeting of conservative tax-exemptions while letting liberal groups qualify with qualms as selective economic brutality.   It may be worth noting that the head of the IRS visited the White House 118 times in two years, presumably to prepare Obamacare for IRS intervention and enforcement.

Conclusion

Using the end of the cold war as a tectonic metaphor for the end of Obamacare is a stretch.  Nevertheless, there may be a few elements of similarity – the decline of the importance of central planning,  the impotence of this planning in causing economic growth,  the apparent  use of the a central government agency to undercut one’s ideological opponents, and the impact of consumers as a tectonic force in upending government because of continuing record levels of unemployment.  
I do not foresee Obamacare coming to an abrupt end.    The political parties representing government and the markets are too evenly matched, and the party in power will retain its veto power through 2016.  Its authority to force businesses, physicians, and other elements of health care economy may diminish, but it still retains the bully pulpit,  has an existing law on its side,   appeals to millions  dependent on the government dole' has, for the moment at least, the media on its side, and is about to launch a multimillion PR campaign to “sell” Obamacare.

Tweet:    Despite tectonic forces that may erupt and end Obamacare,  this is not likely to happen given the political circumstances

Second Wind  Physicians

Documented experiences of the second wind go back at least 100 years. The phenomenon has come to be used as a metaphor for continuing on with renewed energy past the point thought to be pas one’s prime, whether in sports, careers, of life in general.

Second Wind, Wikipedia

Mid and late career physicians are retiring in record number from private practices.  Some are quitting because of discontent with the present practice environment.  Others cease independent practice because of economic pressures.  Still others are going work part-time,  being employed by hospitals,  or entering cash only  or concierge practices.  For whatever reason,   health reform has resulted in a sharp decline in traditional private practices associated with 3^rd party payments

Yet many of these  physicians  still believe they have something to offer society.    They feel  they have the energy and experience to develop a second wind.  They seek concrete ways to launch a second career.

I’ve been brainstorming with Tony Kubica of Kubia LaForest Consulting, a firm for helping individuals and organizations managing career transformations,  whether  they be in the corporate or medical worlds.

In the firm’s latest newsletter, which follows this blog, Tony chronicles the career of my son, Spencer, who left Brooks Brothers, became an Episcopalian Priest at 48, , and who is now in Honduras on a Fulbright fellowship teaching abandoned young girls in an orphanage how to write poetry, watercolor, and take pride in themselves and their heritage.

In our brainstorming, Tony and I have been focusing on persons past 50 interested in pursuing second careers. These individuals wish to remain productive. They want  to contribute to society and to their profession. In this uncertain economy, they also want supplemental income.

Some, like my son, seek to enter more spiritually rewarding professions.  A  recent article  Wall Street Journal,  ”For Second Careers, A Leap of Faith, “ documents how growing numbers of people 50 or older see retirement as a chance to “do good.” They  are turning to divinity schools for a more spiritual life in record numbers and comprise more than 20% of students in theological schools.

But most of us seek to stay in the profession or business we know best.  But how do we market ourselves? How to we connect with persons in the same frame of mind? How do we learn how to function in this brave new world dominated by information technologies?

The answer, other than networking with like-minded persons in the same fix, is often to form a website. But how and who?   Where does find a webmaster? Most of us do not know how to navigate this relatively new “information space.” We need to know the specifics of how to do so. We need a webmaster to sit with us for a morning or afternoon session, to teach us the rudiments of how to efficiently connect with our fellow second winders. We need an economic model that helps us master these new information technologies. That model, which we believe might  involve construction of website, is  just one thing  Tony and I are talking about.

Another approach might be to develop an online forum for “second wind physicians,” in which physicians could communicate with each other, exchange ideas, arrange meetings,  empower themselves to be a positive force for themselves and for society,

If  any of you physicians out there  are seeking a “second wind,”  or wish to show how you have embarked on a second career,  have ideas of how to do so,  or simply want to connect with second winders  I invite you to write me at doctor.reece@gmail.com or call me at 1-860-395-1510 to share your thought,  or contact Tony, whose  contact information is listed below after his newsletter.

Newsletter: May 2013, Kubica Laforest Consulting,  high growth business experts Second Wind Profile: Rev. Spencer Reece Last month we wrote about our new initiative: Finding Your Second Wind. Our Second Wind initiative focuses on people who left the corporate world voluntarily, involuntarily, or to retire. And, we define the corporate world broadly, as any organization in which you received a paycheck on a regular basis. Our first profile was about Dr. Tim Warren, the retired Rhode Island chiropractor who successfully climbed Mt. Everest, reaching the summit on his second attempt. This issue focuses on Rev. Spencer Reece. No, Rev. Reece is not a successful businessman who has earned a lot of money and leads the good life as a result of his second career. Rather, Rev. Reece is an Episcopal priest, who is completing a project in Honduras, where he teaches orphaned girls to express themselves in poetry and watercolors. This is a profile of a man who made an incredible contribution to one orphanage, in one town, in one country. Before we introduce Rev. Reece, here is a paragraph from a profile of him in the Miami Herald: “We live in a world that’s full of hate.” So begins the poem of Katherine Marisol Murillo, a 15-year-old girl who recalls the circumstances that led her to Nuestra Pequenas Rosas, a haven in the middle of San Pedro Sula, Honduras. It’s a city known for its maquiladoras (apparel plants) and murder rate (No. 1 in the world), where abandoned children live in cardboard boxes on street corners and find their nourishment from the charity of others or the city dump. We were introduced to Rev. Reece by his father, Dr. Richard Reece. Dr. Reece is a retired pathologist and prolific writer. His blog is called Medinnovation. He is also a candidate for a future Second Wind profile. After graduating from Wesleyan University (Connecticut), Spencer Reece started a corporate career as a salesman for Brooks Brothers. He rose to the position of assistant manager in the Gardens Mall store in Palm Beach Gardens. He was good at his job, and he was moving up the corporate ladder. But that was his day job. At night, he wrote poetry. For 23 years he wrote poetry, submitting his work often for publication and often receiving rejections. In fact, he received more than 1000 rejection letters during those years. But, he still kept writing poetry. Now that’s passion and commitment. Then, one night, he got a call from Louise Gluck, a Pulitzer Prize winning poet. She called to inform him that she selected his manuscript, The Clerk’s Tale, as winner of the Bakeless Prize for new authors awarded by the Bread Loaf Writers Conference at Middlebury College in Vermont. And that changed everything. Twenty-three years of rejection ended with winning the Bakeless Prize. He received another call a short time later. This one was from the New Yorker. Its editors wanted to publish some of his poems. We wonder if anyone, after seeing his work published in the New Yorker, called him “an overnight success.” He continued working at Brooks Brothers but started volunteering at a hospice. He was nagged by the memory that he once wanted to be a priest (in his twenties he earned a master’s degree in theological studies from Harvard Divinity School). But was it too late? After all, he was now in his late forties. He decided it wasn’t and enrolled in the Berkeley Seminary at Yale Divinity School. While in Divinity School, he worked as a chaplain at Hartford Hospital. In the summer of 2010, he spent two months at Our Little Roses in San Pedro Sula, Honduras, working with young orphaned girls. One night, while he was working as a Chaplain at Hartford Hospital, a young Hispanic boy was admitted. He had been stabbed twenty-five times in a gang-related incident and died shortly after admission. Reece’s frustration was that he did not understand Spanish and was unable to communicate and console the young man’s grieving mother. After graduation, he was ordained an Episcopal priest. Now what; where to from here? He applied for a Fulbright proposing to write a book of poems about Honduras (based on his summer experience at Our Little Roses). He was a runner up. So, he successfully applied for a grant to study Spanish. Then, he reapplied for a Fulbright, but this time he proposed teaching eighth to eleventh graders at Our Little Roses how to write poetry. He won and is now completing his year teaching there. As he wraps up his work in Honduras, he is collaborating with Richard Blanco, the poet who spoke at President Obama’s inauguration, on publishing a collection of poems written by the Honduran children. He also is working with James Franco, the Oscar-nominated actor from 127 Hours, to produce a documentary about the project. The singer-songwriter, Dar Williams, is composing the sound track. They hope to premiere the film next year at the Sundance Film Festival. What a journey. Rev. Reece is yet another example of the power passion, belief, and persistence plays in our lives. From Brooks Brothers salesman to award-winning poet, priest, film maker, he influences the lives of the disadvantaged. In our correspondence with Rev. Reece, he said: ”It was my father who first inspired me to write as I saw him working away as a doctor, but secretly, at night, when he wasn’t doing that hard work, he liked to read and write. I have been lucky to have him.” Note: The information for this Profile was from Joan Chrissos’s April 26, 2013 Miami Herald article plus correspondence with Rev. Reece and conversations with his father, Dr. Richard Reece. Reflections on Finding Your Second Wind: How Should You Approach It? What’s your situation? Did you just leave your corporate job (you may have retired) and are you looking for ways to earn some money. You think starting a small business could be the answer, but where do you begin? What do I do; when do I do it; who can help; how much money should I spend; do I need a website; is there really money to be made online. And the questions rush down on you with the force of a 2000 foot waterfall, or at least it feels that way sometimes. There are many paths, as you can see from our profile of Rev. Reece, but where do you start if your goal is to build an income-producing business? Starting a small business or building an online business is like beginning a new career. It takes time, and it takes hard work if you want to develop sustainable income. Your advantage is experience and skills that you can leverage in starting a new business. The disadvantage is to think that experience and skills will provide a shortcut to creating and building a business. There is no shortcut. We suggest you start with: Taking an inventory of your skills. Define your strengths and weaknesses. Understand what did you did well in your career, what was a challenge, and in what areas you needed the help and skills of others. Understanding your financial position. Quantify how much money you need to live. Determine how much you can afford to invest without adversely impacting what you need to live. Researching the ideas you have. Understanding what you will need to know and do to be successful. And, honestly reflect on whether you are willing to do what it takes to be successful in the terms of how you define success. Rev. Reece was willing to go back to school, earn his divinity degree, study Spanish, and spend a year in Honduras. You don’t have to change your world so dramatically, but we think you get the idea. Baby boomers are entering the post corporate world at an increasing rate (they are turning 65 at a rate of 10,000 per day!), and what many will find is that: They have no desire to stop working (although research shows that many no longer want to work the traditional “40-hour work week”). They cannot live on social security, their 401(k), or their pension if they are lucky enough to have one. They are highly motivated to do what they are passionate and excited about but aren’t quite sure how to start. So starting a small business could be the very thing that excites them the most. A good friend of ours, Richard Grehalva, recently published an ebook that can help you answer these questions and more: The Boomerpreneur Revolution. It’s a quick read packed with powerful ideas on how you should approach Finding Your Second Wind. 132 Governors Drive East Greenwich, Rhode Island 02818 (401) 885-2011 tony@kubicalaforestconsulting.com sara@kubicalaforestconsulting.com www.kubicalaforestconsulting.com yourbusinessgyroscope.com Helping Executives & Entrepreneurs Build Remarkable Organizations through our Integrative Growth Model:

HealthCare Rationing Through Rationalization

People spending more of their own money on routine healthcare would make the system more competitive and transparent and restore the confidence between the patients and doctors without government rationing.

Benjamin Carson, MD,  Neurosurgeon,  Johns Hopkins

If you believe that healthcare is a public good to be guaranteed by the state, then a single-payer system is the next best alternative.  Unfortunately it is fiscally unsustainable without rationing.

Charles Krauthammer, MD,  Psychiatrist turned political commentator

While rationalization at the individual level is a plea for more autonomy, at the social level it is often a claim of power to stifle the autonomy of others.

Thomas Sowell,  Senior Fellow,  Hoover Institute

In political circles,  the word “rationing” is a no-no.   Rationing evokes thoughts of  sacrifice of personal freedoms.  That thought  does not play well in  America,  the land  of freedom and abundance. 

But present healthcare costs, particularly of Medicare, are  unsustainable.   Therefore, in one way or another,  you  must be rational.   You  must “rationalize” – make your case rational or conformable to reason be removing unreasonable alternatives.

If you believe in personal freedoms without rationing,  you argue that the marketplace is the best way of distributing healthcare goods.  Here, consumer cost sensitivities or incentives  are the mechanism for  rationing care.  You do not need to use that awful word “rationing.”   You let price become your rationing tool.

If you believe the state should play the dominant  or exclusive role in distributing and paying for healthcare,  you take different tacks.  

One, you can make it difficult to order, perform, or receive a test or a procedure by creating paperwork that must be waded through or complied with  before the test or procedure can be done.   This  approach leads to delays or obstacles or denials of care, and goes under the headings of  “Rationing by Bureaucracy,” or “Rationing by Waiting.”

Two,   you can control costs by making physicians wards of the state or wards of organizations.    Since physicians do not like  to be considered state employees,  you take the second choice.  You pass a law that creates regulations where physicians need to become hospital employees to have access to capital, resources, and technologies to fight or avoid those regulations.  Or you  create organizations that make physicians “accountable” and create “savings” for the government.   You can call these approaches, “Rationing by Consolidation,” or “Rationing by Accountable Organizaitions.”

Three,   you  can rationalize care by paying only for that care or those procedures or tests that produce  favorable outcomes compared to other forms of care or other procedures and tests.     This is done by  compiling massive amounts of data comparing  one approach to the other under the cover of “outcomes research,” or “paying-for-performance” for those healthcare institutions or individuals who achieve the best results.  This approach is completely rational and is understood by healthcare managers with MBAs and healthcare policy makers with MPHs. Indeed, “”Rationing by Outcomes,”  or  “Rationing by Objectives.”

Tweet:    To make healthcare costs sustainable,  you must “ratio “care by “rationalizing”  care in a way that fits one’s political philosophy.

Obama and Democrats' Health Care Plan

Polling Data

Poll	Date	Sample	For/Favor	Against/Oppose	Spread
RCP Average	3/20 - 5/18	--	40.6	49.8	Against/Oppose +9.2
CNN/Opinion Research	5/17 - 5/18	923 A	43	54	Against/Oppose +11
Rasmussen Reports*	5/17 - 5/18	1000 LV	43	51	Against/Oppose +8
FOX News*	4/20 - 4/22	1009 RV	41	54	Against/Oppose +13
Quinnipiac	3/26 - 4/1	1711 RV	41	46	Against/Oppose +5
CBS News	3/20 - 3/24	1181 A	35	44	Against/Oppose +9

All Obama and Democrats' Health Care Plan Polling Data,

As presented in Real Clear Politics

Tweet:  Polls from 5 national organizations - CNN, Rasmussen, Fox, Quinnipiac, and CBS - indicate 9.2% of Americans oppose Obamacare.

Obamacare: Wait and See and Waiting to Be Seen

Change will not come if we wait for some other person or some other time.  We are the ones we’ve been waiting for.  We are the change we seek.

President Barack Obama, campaign speech, 2008

Americans are an impatient people.  We do not like  like waiting.  We do not like waiting to schedule an appointment to see a doctor.  We do not like  waiting in the waiting room. We do not like wasting a day driving to and from the doctor,  or waiting to find a parking spot, waiting to fill out the paperwork at the doctor’s office, waiting to be seen by the doctor,  waiting to have the prescription filled,  or waiting to see what to see what the Affordable Care Act portends for us.

When 2014 arrives, Americans will have waited four years to see what Obamacare holds for them.  That’s a long wait for an impatient people.   There are hints on what is to come.  Massachusetts has a health bill resembling Obamacare.  In Boston, people now wait 2 months to see a doctor (versus 3 week in the rest of the U.S.),  and  1 in 5 Boston patients leaves the emergency room without being see because they are tired of waiting.

The waiting situation will only grow worse when 2014 comes, when 32 million more patients enter the system courtesy of Obamacare,  and when over the 4 years between 2010 and 2014, the population has grown by 10 million or so and 16 million more aging  Americans will have joined the Medicare ranks,  the doctor shortage will have grown to 50,000,  and 75% of doctors will be working 40 hour weeks as hospital employees. In the 4 years since Obamacare passed, the demand for care will have grown while the supply of doctors to see them will have shrunk.

So what happens in 2014 and what is happeining now?  Well, according to John Goodman, writing in the May 23 issue of Forbes,  “Coming Soon to America: A Two-Tiered System Canadian-Style System,” we’ll have a two-class system. 

·         In the first class system,  i.e, those who can pay  $1500 to $2000 a year,  for the privilege of not waiting, patients will go to concierge doctors, who will see them on the day they call – no waiting there.   Doctors who practice in this system will have pared their patient panels from 2500 patients to 500 in order to give patients the attention they deserve and to eliminate waiting time.  The other 2000 will just have to wait to be seen elsewhere.

·         In the second class system for those on Medicaid, those on Medicare unable to afford the concierge fee, those  on federal subsidies of one sort or another,  or those who simply can’t afford to pay for one reason or another ,  there will be rationing by waiting, whether that be at the doctors’ office, community health centers,  or hospital emergency rooms.
 

The end game will be a waiting game.   Those who can will advance to the head of the line;  those who can’t will go to the end of the line.   Don’t worry, if you are one of the less privileged one, “All things will come round to him who will but wait, ” as William Wadsworth Longfellow (1807-1881)  said in Tales of A Wayside Inn (1863).  You will just have to wait by the wayside  to be seen, and  meanwhile,  you may  have to wait a year or more to see if waiting for Obamacare to come full-bore has been worth the wait.

Tweet:  A 2-tier health system is evolving; one for those with who do not have to wait to be seen , another for those who must wait to be seen.

 

Is More Data The Key to Lower Costs and Better Health?

The combination of Obamacare regulations, incentives in the recovery act for doctors and hospitals to shift to electronic records and the releasing of mountains of data held by the Department of Health and Human Services is creating a new marketplace and platform for innovation — a health care Silicon Valley — that has the potential to create better outcomes at lower costs by changing how health data are stored, shared and mined. It’s a new industry.

Thomas Friedman, “Obamacare’s Other Surprise, “ New York Times, May 25, 2013

Thomas Friedman,  the New York Times influential and perceptive columnist,  has jumped on President Obama’s health care data bandwagon.

Obama and supporters of the health law believe giving doctors instant access to information at the point of care about what works and doesn’t work, and rewarding them for better outcomes will improve the nation’s health.   Not only that,  doctors will cease performing unnecessary tests and procedures, and fee-for-service payments will fade into the woodwork.  At long last, doctors will be paid for keeping patients well, not just for treating them when they are sick.

It’s a plausible theory.  We’re about to find out if theory matches reality. 

Friedman observes, “According to the Obama administration, thanks to incentives in the recovery act in 2008,  there has been nearly a tripling  of electronic  records, and quadrupling of  in hospitals.”

Couple this with rewarding pay-for-performance for doctors, and a health-improvement revolution may ensue.

But the improvement may be modest, rather than revolutionary, as I pointed out in the blog post two and one half years ago.

Lay on, Macduff
and damn’d be him that first cries,”Hold enough!

Shakspeare, Macbeth

In Macbeth, Macduff symbolizes virtue, which should be rewarded but does not always win in the end. The rigid regulators of practice rectitude and worshippers of computer-guided best practice protocols must have been taken back when they read the negative results of a nine year study of 470,000 hypertensive British patients treated by doctors rewarded through pay-for-performance guidelines.

Doctor Incentives Don't Improve Patient care - study

“LONDON, January 26, (Reuters) - Paying doctors financial rewards to meet targets for improving the care of patients made no discernible difference to the health or treatment of people with high blood pressure, a study has found.,

“The findings suggest governments and health insurers across the world may be wasting billions of dollars on doctor incentive schemes but getting no improvement in patient care, researchers who conducted the study said.”

“Researchers from Britain, the United States and Canada assessed the impact of incentivized targets on quality of care and health outcomes in around 470,000 British patients with hypertension and found that they had no impact on rates of heart attacks, kidney failure, stroke or death.”

"No matter how we looked at the numbers, the evidence was unmistakable; by no measure did pay-for-performance benefit patients with hypertension," said Brian Serumaga of Britain's Nottingham Univwersity, who led the research."

What? You mean doctors being paid to follow health reform quality improvement rules may be wasting taxpayer money.

What? You mean outcomes don’t improve.

The neutral consequences of pay-for-performance must come as a shock to those who believe doctors are primarily at fault for the bad performance and shoddy outcomes of health systems around the world.

I would like to humbly suggest there may be a reason for these disappointing results , namely. that doctors cannot change patient behavior once patients leave the office to return to their former lifestyles and to the habits that lead to hypertension in the first place. Patients may continue to have stress, to drink too much, to eat high salt diets, to exercise too little, and to not take their medications appropriately or at all. Genetics play a central role in clinical destinies as well.

There are no prescriptions that can be written or outpatient rules that can be enforced by doctors that will change basic human behavior and habits developed over a lifetime. Perhaps outcomes could be improved through intervention and surveillance by outpatient professionals – nurses, social workers, trained volunteers or visiting doctors- or through technological sensors measuring blood pressures and lipids- but human freedom and the choice to behave as one wishes is another ball of wax beyond the pall of office-based physicians

Tweet:  Giving doctors instant data access via EHRs and rewarding them  for better outcomes  may not  improve patients’ health and  outcomes.

Source:  RReece, “Health Reform and Pay-for-Performance, Not So Fast Macduff, “ Medinnovation Llog, January 30, 2011