Friday, February 5, 2016


ObamaCare Heads Towards the Cliff
Will ObamaCare survive?  Can it be sustained?  If not, why not, who’s to blame, and what’s next?
Questions swirl around ObamaCare’s future,  as UnitedHealth, Aetna, Cigna , and Humana threaten to jump off the health exchange cliff.  The reasons are obvious.  United has lost  $750 million on the exchanges,  $425 million  in 2015, and Aetna has dropped $100 million.  United says it will lose $500 million more in 2016.  These health plans are for-profit enterprises, and they cannot sustain these losses for long,  stay in business, and satisfy investors and other stakeholders.   Add to this the fact that ½ of not-for-profit health exchange co-ops have failed, and the possibility that the GOP may win the Presidency, the House, and the Senate,  and the cliff’s edge looms closer and closer.
Who’s to blame?  The failure of the young and healthy, aged 19 to 34,  to follow the ObamaCare script are taking the hit.  Last year,  the CBO predicted  20 million would sign up for the exchanges, but only 12.7 million did.  The inevitable result was that premiums had to be jacked up for older and sicker patients, or for-profit insurers would have to exit the market. 
The Obama administration assumed the young, facing individual mandate penalties and a short sign-up period, would rush to sign up.   The administration was wrong.   The young knew a bad deal when they saw one,  calculated they had more to gain and less to lose  by not signing up,  and, due to "special enrollment" exemptions , could wait until they were sick to sign on the dotted line.
Who’s  the villain ?   The for-profit insurers, says Bernie Sanders,  the Democrat socialist.   If these insurers  and the for-profit motive did not exist, this problem of insurance losses would not be there.   The solution is Medicare-for-All with elimination of for-profit insurers.   Raise taxes on the rich and middle-class, and let the government  and all the taxpayers take the loss.    Universal coverage is a moral obligation, even if it would cost $15 trillion over the next decade.  Apparently,  the young and healthy agree with Senator Saunders.   Polls indicate 84% agree with him.

Thursday, February 4, 2016


Facts about Physician Assistants

·         Eugene Stead, MD, Professsor of Internal Medicine at Duke,  assembled first class in 1965.

 

·         There are now 108,500 PAs.   67% are women, 87% are white,  and their average age is 38, and 22% speak another language than English.

 

·         There are 199 programs across U.S.   Requires Masters degree to enter.  

 

·         Nationally certified and state licensed.

 

·         Under physician supervision, can conduct physical exams, order tests, diagnose illness, develop treatment plans,  perform procedures,  order preventive tests, assist in surgery.

 

·         Help relieve physicians  of time-consuming burdens.

 

·         Earn $95,000 on average, or $45 per hour, and have debts of $112,500.

 

·         Profession growing fast, one of most desirable jobs in numerous surveys.

 

·         Accepted well by physician supervisors and patients.

Wednesday, February 3, 2016


ObamaCare Is Silent Campaign Issue for Now But Not for Long
These days , during the early stages of a hectic political campaigns, you just hear much about ObamaCare.   Politicians are simply too busy trying to get elected or to keep from getting rejected.  ObamaCare is  too deep and complex an issue to win or lose voters on for now. For the moment, it is best to praise the Lord and hold the ammunition.
But just  wait until income taxes become due and premium increases become known.   Those who choose not to have a plan  will learn it will cost them roughly a $1000.  And premiums overall will go up more than 10% in 29 states  with surges up to 30% or more in half a dozen states.   Increases in individual markets will average 14.7% (“ObamaCare’s Wallet Buster Health Plans,” WSJ, February 2, 2015).
As one cynic observed, “ When they have you by your wallet,  your heart and mind will follow.”  This line of thinking will play in the GOP’s favor, which is why the party voted to repeal ObamaCare even  when it knew it could not override President Obama’s veto.    Democrats are lukewarm about ObamaCare and are promising they will “fix it.”  Cynics may say the voters know the price of everything but the value of nothing.  But price will be an issue in the wake of Obama’s promise that his plan would reduce premiums by $2500 by 2016. 
2016 is here.  The economy is weak,  the stock market is sputtering, and middle class voters are holding onto their wallets.

 

Monday, February 1, 2016


2084
Americans have a lively faith in the perfectibility of man, they judge the diffusion of knowledge must necessarily be advantageous, and the consequences of ignorance fatal; they all consider society as a body in a state of improvement.
Alexis de Tocqueville (1805-1859), Democracy in America
Centerware
It’s 2084.   Everything has its place, and there’s a place for everything.   Everything is digitized. Everything is rational. Everything is transparent.  Everything is comprehensive. 

Everyware information technology reigns.  Hardware and software  are everyware.  Everyware judges quality, efficacy, efficiency, optimumability , acceptability, equity, and costs.  As far as the eye can see and the mind can grasp, there are devices, apps, algorithms, protocols, and guidelines.    

Everything is systematized.   Everywhere every aspect of health care is  precisely predictable, ideally  structured,  with rigid processes in place,  with machine predetermined  outcomes .   

Everything can be made  virtual.  All knowledge is accessible. If  you can’t get it yourself, drones will bring it to you.  Every patient is empowered  with universal digital knowledge.   Everyone can monitor themselves, or be monitored by others  from afar.  

Everything is integrated. Everybody is interconnected to the nth degree. All electronic health records are interoperable.  Interdigitation  rules the land.

Physicians are cogs in machine,  responsive and responsible only to the data systems they must feed and  that guides them.

Data is language.  Collectivism is individualism.  Artificial intelligence is king.

And Big Brother,  Big Sister,  Little Brother, and Little Sister are watching you, guiding you, and directing you to a more perfect world.

To err is human,  to forego data malign.
Edgeware
If you are designing a machine, you had better think of everything because a machine does not think of everything.
B.Zimmerman, C. Lindberg, P.Pisek, Edgeware: Insights from Complexity Science for Health Care Leaders, 1998
Edgeware followers  beg to differ from Centercare  cognoscenti.    The Edgeware crowd maintains health care  realities  and human relationships are  so complex that there is  not a place for everything,  and not everything has a place.  

Data cannot predict everything,  and humans must  always have freedom of choice outside the sphere of data  at the end of the data rainbow. 

Humans are not perfect.   Nor are their  machines.   Humans have souls.   They live at the edge of humanity, where human disagreements, gossip, and desire for change  exist at every level of human activity.  

Humans are  imperfect.  That’s what makes them unpredictable and  changeable - and human.  

Edgewarians do not have perfect vision, but  it’s good enough for human consumption,  and they do not need to know every detail in advance  or from the past.    They are tuned to the edges of reality.  They  can build a good-enough vision and follow minimal standards rather than trying to work out every detail.  

They like to go for  multiple actions and to test every human  action  at the fringes, letting the right direction emerge  rather than believing they  must be sure before proceeding with anything. 

They like to “chunk,”  trying small things out of simple actions that work well independently rather than listening to the machine.   

Doctors like to  listen to  patients, and patients to their doctors, with both acting in  collaboration and cooperation with each other rather than blindly listening to some higher authority or digitally-driven machine.

To err is human, to go offline is benign.

 

Sunday, January 31, 2016


High-End Immigrants: Their  Insight into America
A moment’s insight is sometimes worth a life’s experience.
O.W. Holmes (1809-1894),  The Professor at the Breakfast Table
I’ve been reading a book, The Road to Home, by Vartan Gregorian, Simon & Schuster, 2003
Vartan Gregorian  is an 81 year old Armenian immigrant who migrated to the U.S at age 22 in 1956,  earned a PhD in History at Stanford, held professorships at 4 American universities,    became President of  Brown University,  the New York Public Library, and the Carnegie Foundation.
I mention these accomplishments because Dr. Gregorian, like many highly skilled and learned immigrants,  had the insight to instantly recognize America’s greatest assets – its limitless opportunities,  its freedoms to rise, and its immeasurable   natural human and physical resources.
Here is Gregorian giving his insights upon  his arrival:
“My first impressions of Americans during my first two months were many and varied.  I wrote in my diary that Americans don’t like to be bossed or told what to do by anyone,  nor their government nor their clergy or their employers.  They must believe they are acting on their own volition.  Americans are very individualistic.  They work hard, they are open, kind, and generous.”
And here is Gregorian, sharing his views  after assuming a professorship at the University of Texas and living in Austin.

“Texas was huge! It was an endless frontier. It was a proud, self-confident, optimist state. It was the land of “Why not?” and “can do.” Whether you  know  it or not,  while in Texas you had to think big. With size went a swaggering boastfulness…Texas had the biggest horizons, the biggest skies, and the largest number of stars.  In Texas, you never felt constrained  You never felt claustrophobic  The whole state was restless and on the move.”
More than anything else immigrants recognize America as the land of opportunity, of "why not?" and "can-do."    
Peter F. Drucker (1909-2005), an Austrian immigrant and the father of management as we know it,  said it best on how to succeed in American business.
“Courage rather than analysis dictates the truly important rules for identifying priorities;
·         Pick the future as against the past. 
·         Focus on opportunity rather than on problem.
·          Choose our own direction – rather than climb on the bandwagon.
·         Aim high, aim for something that will make a difference, rather than for something that is    'safe' and'easy' to do.”
hHighly skilled  immigrant entrepreneurs  recognize America as their future home   Forty-three percent of Silicon Valley founders and  CEOs are immigrants.  These include Sergey Brin, co-founder of Google, and Safra Catz, CEO of Oracle.  Small wonder that Silicon Valley lobbyists are fighting a running battle to loosen restrictions on H-1 visas for entrepreneurs from abroad.  
bBefore I end this blog post,  let me remind readers that 25% of physicians practicing in America are foreign-trained immigrants,  including anesthesiologists, 31%, cardiologists, 31%.,internists, 32%., nephrologists, 40%, psychiatrists, 31%, family physicians, 35%.  Immigrant doctors too want to share the American dream of freedom and opportunity.

 

Saturday, January 30, 2016


The World of Inversions
The world is being turned upside-down and inside-out  in the world of politics,  as well as the worlds of business and  health care.
The act of inversion is to reverse positions, directions, or relationships,  to turn inside-out, or upside-down, or topsy-turvy
In politics,    Donald Trump  and the Bernie Sanders  lead the inversion  list.  Suddenly,  Trump, a businessman with no direct,  inside political experience,  and Sanders,  a long-avowed Democratic Socialist with 25 years in Congress,  but also no political insider,  are suddenly leading their respective political parties.    Both  are political outsiders leading  “revolutions,”  and new political merry-go-rounds, whether they will stop nobody knows.    Trump appeals to  lower and middle class working voters, who have tired and suffered from  economic slow growth and unfulfilled government promises,  and  Sanders attracts the young, idealistic,  and the liberal elite,   who believe in or  seek government largesse and power  using other people’s money.
In business,  inversion  goes by the name of tax inversions, whereby corporations relocate their headquarters in a lower tax nation, or corporate haven ,  while maintaining their operations in the higher tax nation.    This is often done by acquiring a company in the lower tax nation.   In the $100 billion dollar Pfizer-Allergen deal,  Pzifer would lower its overall-tax burden from 25% tp 17%,  saving $1 billion in the process.   Fifty one companies  have done tax inversions,  including Tyco International,    Pfizer, Medtronic, and Burger King,  and other big companies  are considering tax inversion.   The driving force is  the punitive U.S. corporate income tax, which,  at 35%, and effectively 39%, is the highest in the world.   For most  companies, the favored corporate havens are Ireland,  the U.K,  Jamaica, or elsewhere in the Carribean, and in the case of Burger King,   Canada.
With health care,   pharmaceutical companies and health care corporations  favor Ireland as a haven.   With hospitals, physicians, and consumers the inversions  are relocations to a different site or a different way of practice within the U.S.      Hospitals seek markets and switches of operating sites outside the hospitals,  often in acquired  physician practices and generally in the suburbs or  regions or states in which they dominate.   Physicians tend to convert traditional practices  to direct, cash-only practices, outside the reach or participation  in 3rd party government or insurance programs.   As  for consumers,  who can no longer afford  high premiums or deductibles,   the inversion targets are home care,  direct cash practices, self-care, or reliance on the Internet for information and self-monitoring devices.   One side prides itself on following the dictates of its conscience and its moral imperatives,  other on its common sense and its state of economic  despair.