Sunday, September 21, 2014

Patients, Physicians, and Pluralism

The theory that even if there is one basic principle many particular and distinct entities exist.


I belong to the school that says.

• America is basically a conservative right of center pluralistic nation that cherishess economic growth more than in political egalitarianism.

• America believes in equality of opportunity but not necessarily in redistribution of wealth to achieve equality of results.

• Diffusion of electronic communication technologies is making top-down autocratic homogenization of population behavior difficult, even obsolete.

• Conservative politics generate economic growth but result in inequality while left-wing politics redistribute wealth to achieve equality but produce economic stagnation.

• Finally, I believe these political philosophies will always swing back and forth in never-ending political and economic cycles with neither side ever convincing the other of the rightness of their respective causes.

At this moment in history, the U.S. and the world are caught up in the causes of pluralism vs. separatism. This dispute is exemplified by the struggle of who should control health care in the United States, the collective government or individual markets, by the Scottish referendum over whether Scotland should be independent or dependent on Britain, and by the Middle Eastern battles over which political entity should govern in that region of the world.

In his essay in this morning’s New York Times, Thomas Friedman backs pluralism over separatism “Three Cheers for Pluralism over Separatism.” Friedman argues everybody’s interests have be served and balanced with “no victor, no vanquished” among major players.

Friedman goes on to say America has always been a pluralistic country and concludes by saying we ought to have the wisdom to pass an immigration reform bill that enriches our pluralism.

Like most hot political issues, integrating the interests of those with different points of view is easier said than done.

As Peter F. Drucker (1909-2005), noted in his prophetic 1969 book, The Age of Discontinuity, in a chapter “The New Pluralism”:

“The private sector does not understand the government’s logic. Each rubs the other raw trying to work together, each resents the attitude of the other and is deeply suspicious of it, and yet each other is dependent on the other…Medical men see individuals. Indeed, none of us would want to be treated by a physician who treats ‘averages.’ But no government can handle anything but large numbers or go by anything but averages.”

But work together we must in a nation where 280 million of our 315 million citizens are dependent in one way or another on government subsidies: 65 million on Medicaid, 50 million on Medicare, 9 million on the VA, 7 million on ObamaCare exchanges, and a whopping 149 million on corporate health care tax credits for employers .

We must do so to preserve a society that is both competitive but cohesive despite our differences

Saturday, September 20, 2014

Electronic (E) Technology Doxology

Praise E-technology, from whom all blessings flow.


In God we trust, all others bring data.

W. Edwards Deming. 1900-1993.American statistician

Electronic (E) Technology has become a religion.

It's E-Technology here, E-Technology there, E-data here, E-data everywhere for every season and every reason as far as the Electronic Global eye can see.

It’s computer, mobile, and Internet apps. It’s Alibaba, the giant China E-commerce company. It’s Facebook, Twitter, and Amazon. It’s “Technology Lights Up Health Innovation Forum.” “It’s the Apple iPhone Takes Over the Street.” It’s “Leapfrogging the Democrat’s Tech Advantage.” It’s “Three Ways to Take Advantage of the Cloud.”

It's viral. It spreads through the ether, through the Cloud, from E-mail to E-mail, from Website to Website, from person to person.

It’s the multiplier, emusifier effect.

Why fool around with hundreds of thousands in the long term when you can reach millions, even billions, and disperse the information all at once?

Why wait for results when you can measure outcomes instantly with real data ?

Why be subjective with feelings when you can be objective with data?

Why guess when you can make others know?

Why wait to become a billionaire when you can do in a twinkling with Twitter?

Or connect with billions with Facebook?

According to three dozen experts who gathered this week in Boston for an innovation conference, a tsunami of health care innovations is sweeping the globe.

These innovations, say the expert schemers and dreamers, will be cost-effective and will boost wellness, prevention, precision treatment, personal and decentralized care at the iPhone, social media, personal, and home-bound levels.

It will be an E for an E, an E-click for an E- click, and an E-bite for an E-bite, one on one for millions.

Well, we shall see.

We shall see innovation and 3000 troops on the ground wipes out Ebola.

We shall see if the over all and individual health of Americans improves.

We shall see if the results match the rhetoric.

We shall see if innovation creates necessary economic growth, requisite market competition, needed consumer choices, and required price transparencies.

And we shall see whether collectivist governments have the wisdom to abet the innovative process or strangle it because it generates that dreaded thing called profit – a universal incentive for prosperity and the betterment of humankind.

Friday, September 19, 2014

President Obama's Judgment V. the People's Judgment

Any social order which can function well with a minimum of leadership will be anathema to the intellectual

Eric Hoffer (1902-1983), American longshoreman, moral and social philosopher, In The True Believer (1951)

I collect Eric Hoffer books. I think of him as "His Earthiness", a man with his feet solidly on the ground.

Among other things, Hoffer has said you cannot trust an intellectual to be President because he does not reflect the sentiments of the people.

Obama considers himself as one of the elite, who knows what needs to be done.

President Obama has inpeccable academic credentials – Columbia University, Harvard Law, and Professor of Constitutional Law at the University of Chicago. He is smart. He is a real, genuine, certified intellectual, with two best-seller books on the New York Times book list. He is a smooth talker. He is facile with words, especially when reading from a teleprompter. He is quick with concepts. He absorbs data and information like a sponge. He is an integral inseparable part of the Media-academic-Washington-elite-policy Complex.

But he may be out of out of touch with the populace, as evidenced by these latest Real Clear Politics polls based on average results of major national polls.

• Obama Job Approval, Approve 41.3%, Disapprove 53.4%

• Direction of Country, Right direction, 27.4%, wrong direction 64.6%

• Approval of Health Law, favor 41.3%, oppose 51.4%

Is it possible the President lacks wisdom and judgment on how best to lead the country, how to get the country behind him on critical issues relating to the economy, to joblessness, to health care, to foreign affairs? Is it possible the President is too long on rhetoric but too short on results?

Does he lack the wisdom to lead the country? Does he understand wisdom of crowds, whose support he needs and who must live under his leadership? Is the President like the man described by Albert Camus (1913-1960), who said, “An intelligent man on one plane can be a fool on the others.”

To Peggy Noonan, a staunch Republican writing in yesterday’s Wall Street Journal, “ The Unwisdom of Barach Obama – Is He Weak? Arrogant? Ambivalent?"

Noonan say the President’s problems– his being out of touch on economic issues, health care, foreign affairs, his own advisers and generals – is not lack of wisdom.

It is simply poor judgment , of not seeing the domestic and global forests as seen by others while looking too intently at his own trees.

“He has very poor judgment. Maybe all this is the president's clever way of letting time pass, letting things play out, so that in a few months the public fever to do something—he always thinks the public has a fever—will be over. And he will then be able to do little, which perhaps is what he wants.But none of this looks clever. It looks like poor judgment beginning to end.”

For President Obama, his day of judgment is approaching in 46 days with the November 4 midterm elections. We shall see then whose judgment prevails - his or that of the people.

Thursday, September 18, 2014

ObamaCare in Perspective

Everything we hear is an opinion, not a fact. Everything we see is a perspective, not the truth.

Marcus Aurelius (121-180 AD)

These days I am spending a lot of my time trying to keep things in perspective.

I am watching the excellent PBS series on the Roosevelts and the different perspectives on Theodore Roosevelt, a Republican Progressive. and Franklin Roosevelt, a Democratic Progressive, both pitting their parties against the rich, and I am reading Karl Rove, “Why A GOP Majority Is Still in Doubt,” WSJ, September 17. The reason, says Rove, is that Democrats have more money and are outspending the GOP $109 million to $85 million on negative TV ads.

This discrepancy makes me wonder, who is the party of the rich?

My aim is to keep matters in perspective, rather than going off half-cocked.

It isn’t easy.

Take the ISIS beheadings of 3 innocent hostages. The beheadings are gruesome, but they may not foretell of the unraveling of Western civilization, an argument advanced by Robert Cohen of the ew York Times )”The Great Unraveling, September 15).

Or consider today’s Scottish referendum whether to declare independence from England. I doubt this is the end of Scotland if they vote Yea ( Niall Ferguson, “Alone, Scotland Will Be a Failed State," The Telegraph, September 18).

Or, for another matter, take the ObamaCare political situation. The three beheadings, ISIS aggression, and speculation about troops on the ground have pushed ObamaCare into background. ObamaCare, say the pundits, has become a nonfactor in the Senate election (David Nasher, “ObamaCare from Game Changer to Background Noise, “Politico, September 17).

From my perspective, the Senate outcome may or may not seal the fate or keep ObamaCare alive.

• Whether Democrats or the GOP wins the Senator or a tie occurs, given Obama’s veto power, gridlock will continue for the rest of the Obama presidency.

• As pointed out in yesterday’s blog, ObamaCare exchanges cover only 7 million Americans, just 3.2% of the population, and even if 5 million are added in the next enrollment go-around starting November 15, only 3.8% will be insured. If ObamaCare goes as predicted until 2013, 30 million of 9.5% of Americans will be left uninsured.

• The American public opposes ObamaCare but does not want it repealed and wants certain changes kept (young adults covered under parents’ plans and coverage of those with pre-existing conditions). To date, the number of uninsured has been reduced a scant 2%.

• Despite all the hubdub, we sometimes forget a nation’s health system accounts for only 15% of a nation’s health status; life style is 30% and other factors – poverty, inferior education, income differences, and lack of social cohesion ofor the other 55% (Satcher, D, and Pamies, R, Multicultural Medicine and Health , McGraw Hill, 2006),

We forget too that since 1965, when Lyndon Johnson declared the war on poverty, we have spent $15 trillion on poverty and the rate of poverty remains at 15%, the same as it was then.

And finally we tend to neglect the fact that under President Obama, income inequality between the rich and the poor has widened, and income of the middle class has fallen 10%. To paraphrase George Orwell, despite progressive politics, all humans are equal but some remain more equal than others.

Wednesday, September 17, 2014

Quote to Note: Who Says America Is Not a Compassionate Nation?

"The non-surprise revealed here is that ObamaCare turns out to be just another subsidy program, throwing money at health care. In economics, you can't subsidize everybody but we're trying: 50 million Americans get help from Medicare, 65 million from Medicaid, nine million from the Department of Veterans Affairs, seven million (and counting) from ObamaCare, and a whopping 149 million from the giant tax handout for employer-provided health insurance."

Holman Jenkins, “ObamaCare and American Resurgence,” Wall Street Journal, September 16, 2014

P.S. This means 280 Americans out of our 315 million population or 88.9% receive health care subsidies in one form or another from the federal government.
Population Health Management Era Arrives

The Affordable Care Act, as well as changes in how employers and insurance companies address health care, will try to change these disincentives (individual fee-for-service overuse) and encourage health-care providers to manage populations. A population may include a company’s employees and their families, a union’s members, a group of individuals who purchase a like product on the insurance exchange, or a group of Medicare or Medicaid beneficiaries.

Kenneth Davis, MD, CEO and president of Mount Sinai Health System in New York City, “Hospital Mergers Can Lower Costs and Improve Medical Care," Wall Street Journal, September 16, 2014

We are now in the Population Health Management Era.

The big data revolution made it inevitable. You can now connect instantly connect everything with everybody. You can calculate outcomes for different conditions for different populations. You can measure the overall health of different populations in different states and regions under different health systems. You can compare results. You can evaluate the impact of health reform. Above all, you can “manage” care for large groups of people rather than deal with individual problems. Managing populations and their health is said to be easier, less costly, and more efficient than directing and controlling health of individuals.

What’s not to like? Population health management is rational. It is objective. It is controllable. It lends itself to large organizations, like hospitals, who can now coordinate care, get hospital departments and specialists to work together with caregivers, measure health care improvements.

Besides, as Doctor Davis says, “Physicians participating in larger networks will be able to learn more about the best treatments because they will have larger populations from which to draw conclusions.. one can apply supercomputer resources to mine the data and create predictive models of disease….help individuals better understand their risk of illness, and customize preventive or treatment strategy.”


It is a very persuasive and seductive argument, but it has downsides – loss of personal privacy, narrowing of personal choices, erosion of physician autonomies, and an over reliance on data and actions of policy makers and health executives rather than clinical judgments of patients and their physicians.

Carrying out population health management programs is expensive. It requires major technology investments, faith that electronic medical record system will bring efficiency rather than impediments, a belief that various computer system will flawlessly communicate with one another, and “an army of care coordinators to serve as a backbone of an integrated care team.”

Patients and physicians are not yet convinced that population health management, as envisioned by the Obama administratio and large health sysems is the way to go. Four and one-half years after ObamaCare’s enactment, the public consistently opposes the health law by 10 % to 15% margins. And a just released survey of 20,000 U.S. physicians indicates only 24% say electronic medical records have improved efficiency while 46% say they distract from patient care, and only 25% give the Affordable Care Act an A or B grade while 46% give it a D or an F.