On Explaining the Health Law Simply

I wish he would explain his explanation.

Lord Byron (1788-1824), Don Juan

If you can’t explain it simply, you don’t understand it well.

Albert Einstein (1879-1955), Sayings

Why is President Obama having such a hard time explaining the health care law simply?  Why can’t he simply explain it in one paragraph? Or explain it in terms simple folks, who are groping for an explanation, understand?

The simple explanation? It’s complicated. It effects every American. It’s 2700 pages long. It’s written in legalese. It requires 15,000 to 20,000 pages of regulations to enforce. 

Another simple explanation is that it has taken four years of rollout. It’s difficult, if not impossible  to follow its shifting  permutations, combinations,  and deviations.

Another  simple explanation is that it’s unilateral partisan passage under questionable circumstances poisoned the political well, inviting devisive, obfuscating, non-believing political opposition. 

Yet another simple explanation is that it means so many things to so many different people at so many different times in so many different ways at so many different levels, that nobody understands it , which explains why Surviving Obamacare, which explains it to  each and every constituency, is a runaway best seller.

The final simple explanation  is that you cannot explain simply a one-size-fits-all- top-down controlling,  centralizing philosophy to a national audience that  prefers bottom-up personal choices and freedoms.

Why Explain?  It’s the Law

On the other hand, why explain?  As the poet, W.H. Auden explained,

Law, says the judge, as he looks down his nose.

Speaking clearly and most severely,

Law is as I told you before,

Law is as you know I suppose,

Law is but let me explain it once more.

Law is the Law.

The law, after all,  is the law.  It’s the law’s way, or the highway.

You need not simplify the law, or apologize for the law,  or explain the law. That would be a sign of weakness.  

In other words, what is is. The law, in short, is immutable, with all of its flaws.

But What If?

But what do you do if the law is weak, not carefully thought through,  loaded with adverse consequences,  more expensive than promised,  riddled with loopholes,  and slow and tortuous to implement?

What if people prefer the status quo to a government hammer throw?

And what do you do, when, three years after its passage, it has  failed to live up its promises  - to lower costs,  to protect patients, to improve access, and to improve care.

Then, what do you do? You try to explain the law,  you revisit it,  you clarify it,  you amend it,  you tweak it, you offer waivers to your friends,  you revise it, but never, never, do you repeal it or admit it might fail.  None of these action, alas, make it simpler to explain.

In the end,  what do you do,

When your health law you can’t simply explain,

Or explain simply,

When most of the people still complain,

Or deem your explanations as limply,

When it effects every constituent in a thousand different ways,

When the law is a bewildering, convoluted health care maze,

What do you do?

You blame the opposition  in language  profane,

You accuse them of being unfeeling and inhumane,

For not understanding the depth of your knowledge,

And the profound wisdom of the electoral college.

Tweet:   Beyond good intentions, the convoluted health reform law is difficult and impossible to explain simply.

Sixteen Quotes from Margaret Thatcher (1925-2013)

1.      “In politics, If you want anything said, ask a man. If you want anything done, ask a woman.”

2.  “The problem with socialism is that you eventually run out of other people's money.”

3.      “Being powerful is like being a lady. If you have to tell people you are, you aren't.”

4.      “If you just set out to be liked, you will be prepared to compromise on anything at anytime, and would achieve nothing. ”

5.      “You may have to fight a battle more than once to win it.”

6.      “Do you know that one of the great problems of our age is that we are governed by people who care more about feelings than they do about thoughts and ideas.”

7.      “Don't follow the crowd, let the crowd follow you.”

8.       “I always cheer up immensely if an attack is particularly wounding because I think, well, if they attack one personally, it means they have not a single political argument left."

9.      “When I'm out of politics I'm going to run a business, it'll be called rent-a-spine”

10.  “Europe was created by history. America was created by philosophy.”

11.   “There is no such thing as society. There are individual men and women, and there are families. And no government can do anything except through people, and people must look to themselves first. It's our duty to look after ourselves and then, also to look after our neighbor. People have got the entitlements too much in mind, without the obligations. There's no such thing as entitlement, unless someone has first met an obligation.”

12.  “Socialists are happy until they run out of other people's money.”

13.  “Being democratic is not enough, a majority cannot turn what is wrong into right. In order to be considered truly free, countries must also have a deep love of liberty and an abiding respect for the rule of law.”

14.  “No-one would remember the Good Samaritan if he'd only had good intentions; he had money as well.”

15.  “To those waiting with bated breath for that favorite media catchphrase, the U-turn, I have only this to say, ‘You turn if you want; the lady’s not for turning."

16.  “There are significant differences between the American and European version of capitalism. The American traditionally emphasizes the need for limited government, light regulations, low taxes and maximum labor-market flexibility. Its success has been shown above all in the ability to create new jobs, in which it is consistently more successful than Europe.”

Tweet:  Margaret Thatcher Lessons – Lead from front, speak your mind, keep at it, put iron in your spine, people are more important than government

A  Practitioner's Journey from Solo Practice, to Managed Care, to Obamacare
 

A Long Day’s Journey into Night.
 

Eugene O’Neill (1888-1953),  Title of 1956 play

Up, lad, When the journey is over, there’ll be time enough to sleep.
 

Alfred Housman (1859-1936) A Shopshire Lad (1896)

In 2003 I wrote a book A Managed Care Memoir: A Physician’s Whistle-Stop Journey (Infinity Publishing.com.) The book chronicled my 27 step managed care journey from Minneapolis to Old Saybrook, Connecticut.  It speculated on what lay beyond. The metaphoric vehicle was the HMO locomotive with stops at Minneapolis, Oklahoma City, Cambridge, Massachusetts, San Francisco, Vail, Colorado, Nashville, Denver. Austin,Texas, Fort Worth, Wilton, Connecticut, Saratoga Springs, New York, Cochrane, Georgia, and Jackson ,Wyoming.

I thought of  my journey when I read about the journey of  Ed Marsh, MD,  an ex-pediatrician who now grows Christmas trees in Upswich, Massachusetts. In today’s WSJ, he writes of his journey from an idealistic medical student to a disillusioned ex-practitioner, “Reflections a Medical Ex-Practitioner. ” He chronicles his trip from  his 1962 medical school graduation, post graduate training ,  to solo practice,   to closing his practice to participate in a “prepaid group " practice, to retirement to raising Christmas trees in Upswich.

Dr. Marsh, in moving, cogent, colorful, and flowing prose, captures the essence of the evolution of medical practice over the last 50 years.

·         Of medical school and setting up a solo  practice. “.When I graduated from medical school in 1962, the profession of medicine was for many graduates an opportunity to provide care—as distinguished from, though aligned with, treatment—and to provide it to individuals, not to populations or governmentally specified groups. Young doctors hoped to establish an independent business, enjoy lifelong intellectual excitement as knowledge and therapies expanded, and have an income sufficient to live decently and support a family. There have always been some who entered medicine, as with any vocation, to maximize income. Yet most of us who came into the profession in the early 1960s had modest financial aspirations and substantial social commitment.”

·         Of solo practice - After eight years of postgraduate study, I opened a solo pediatrics practice in a community of 10,000 souls an hour from Boston. A number of lean years passed before I could build a robust practice. Yet the experience was exactly what I—and I think many of my colleagues—sought: a personal, direct and unimpeded relationship between me and those who chose to become my patients.
 

A major cause of financial stringency was that there was almost no insurance that covered pediatric care in the office setting. Many pediatricians felt denigrated because the care that they were providing was not regarded as sufficiently consequential to be covered by third parties, as was that of their brethren in internal medicine. Surveys always showed pediatricians to be the poorest-paid of all the specialties.

·         Of the entry of managed care and physician and patient reactions- Then, in the mid-1970s, things changed, and we became enlightened. Third parties, typically the insurance companies, were interpolated between the physician and the patient. Some of the consequences were unfortunate.

Patients knew that any suggestions I might make would have negligible consequences for their own budgets, so "more" became the expectation. A sense of entitlement developed. Why would the doctor hesitate to do some procedure, or hesitate to request a test? Everything was already paid for. If I was reluctant, perhaps weighing the cost to them, patients speculated there must be some hidden reason. Perhaps I was, in some obscure way, feathering my own nest. Misgivings arose.
 

This mistrust heightened—and became rational—when "prepaid" group practices became more prevalent. Physician compensation is tied to "efficiencies," which means reducing the outlays and costs to the group (translation: skimp where possible) and thus generating for internal distribution a larger share of the prepaid practice.
 

Second opinions proliferated, upping the costs. Patients could get two opinions for the same price: near zero. I could acquire additional knowledge from the feedback of the consultant and was better positioned should some legal controversy arise. One under examined aspect of defensive medicine is those excessive referrals to diminish responsibility.

·         Of why he left solo practice to join a prepaid group - Insurance relationships drove practice relationships. Patients were more likely to come to me because their insurance told them to, and more likely to leave, despite our congeniality, because their insurance required it. Thus our dealings were less personally rewarding, for my patients and for me.
 

When it became increasingly difficult to work according to my principles, I closed my practice, first joining a "prepaid" group for 15 years, and then leaving patient care altogether. As more physicians leave active practice, it must be appreciated that a focus on the economics of health care is not the only, and perhaps not even the most important, reason for their disillusionment. The glow of the personal relationship one might have with one's patients is being extinguished.

·         Of Obamacare and the end game - When it became increasingly difficult to work according to my principles, I closed my practice, first joining a "prepaid" group for 15 years, and then leaving patient care altogether. As more physicians leave active practice, it must be appreciated that a focus on the economics of health care is not the only, and perhaps not even the most important, reason for their disillusionment. The glow of the personal relationship one might have with one's patients is being extinguished.

The medical economist Rashi Fein observed in 1986 that there are only three ways to limit the extravagant demand for medical care: "Inconvenience," the practice used in the military, where one must wait interminably for care. "Rules," the third-party approach by which layers of rules and thousands of regulations are devised, most recently in a fool's quest to contain costs under ObamaCare. And "Price." ." This last option elicits gasps and chest-clutching from bien pensants who insist that all financial impediments to care must be removed. Yet it has one incontestably beneficial attribute: It requires the physician to study the true cost and benefits of a course of action, and then to present that data to the patient. Who is better suited than the patient to assess the value to him of the proposed treatment? Kathleen Sebelius? You gotta be kidding….

ObamaCare will, deliberately and by design, destroy what—while imperfect—has served very well. We have gotten to this point after years of good intentions making bad problems worse. To double down on the very therapy that has brought the system to its present sorry pass is a toe-ticket to the morgue.

Dr. Marsh’s eloquent rage reminds me of poet Dylan Thomas’s classic poem, “ Do Not Go Gentle into That Good Night,” which opens with this stanza:
 

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Tweet:   The journey from solo practice, to prepaid care, to Obamacare has taken the glow off of doctor patient relationships and joy of practice.

 

Obamacare and Cancer

I’ve been asked to discuss these subjects.

·       The Affordable Care Act – its potential effects on inpatient and outpatient treatment of cancer patients.

Cancer accounts for 23% of deaths and 12% of all health costs. Because of our aging population, advances in technology, and expensive anti-cancer drugs, its costs are rising at 20% a year.   Because of Obamacare, physicians and hospitals are rapidly consolidating into large integrated organizations to deal with federal regulations, administrative demands, costs of installing information technologies, and demands for value-evidence-based approaches to contain costs and offer more systematic team based approaches to care.    Cancer treatment has improved.  There are now 11 million cancer survivors.  Many are elderly and expect the best care modern medicine can offer.

The effects of this will be multiple.   Inpatient care  or care dictated by large organizations will grow,   costs will increase, cancer departments within hospitals will proliferate,  protocols to treat cancer will become the norm,    demands by patients to be referred to leading cancer centers (Sloan-Kettering, Smile at Yale,  Boston-based teaching centers, MD Anderson in Houston) for comprehensive  centers that  treats all aspects of cancer, second opinions,  comparative statistics, and access to the latest technologies and teams of experts, will become a growth industry.  Palliative care will become a medical specialty, and subspecialties – oncology nurses, oncology pharmacists – will be much in demand.

·     Specific issues being faced by physicians in the field of oncology particularly in hospital and managed care settings.

These issues will include: 1) how to coordinate care with other doctors (primary care, diagnostic and radiation oncologists, social workers, home care nurses, and hospice-based nurse practitioners, to name but a few), 2) how to deal with the political controversies surrounding “death panels” and end of life counseling; 3) whether to become an employee of the hospital or large cancer organization. 4) how to facilitate the entry of patients into clinical trials, so that patients can afford anti-caner drugs;   5) when and how to tell patients  to withdraw treatment and to refer them for palliative care; and  most immediately, 6) how to survive in practice with the latest sequester,  which calls for 2% Medicare cuts.  These cuts are across the board and apply to the basic Medicare fee plus the cost of anti-cancer drugs and the 6% added to cover the average cost of drugs.  Oncologists are saying these amounts to an overall cut in their Medicare fees.   Since the typical oncologist has 300 to 350 Medicare patients and this cut reduces their revenues by $400 per patient, many oncologists say they cannot afford to treat new patients and are turning away thousands of Medicare patients.  The choice is between seeing Medicare patients or staying in business.

Beyond this there are the problems of primary palliative care and specialty palliative care, as outlined in the March 28 NEJM (“Generalist plus Specialty Palliative Care – Creating a More Sustainable Model”) outlined as follows.

Primary Palliative Care

1.      Basic management of pain and symptoms

2.      Basic management of depression and anxiety

3.      Basic discussions about – prognosis, goals of treatment, suffering, code status.

Specialty Primary Care

1.      Management of refractory patina or other symptoms

2.      Management of more complex depression, anxiety, grief, and existential distress.

3.      Assistance with conflict resolution regarding goals or method of treatment – within families, between staff and families, among treatment teams.

4.      Assistance in addressing causes of near futility

 

·     The role of pharmacists in care of cancer treatments, particularly in serving as members of multidisciplinary care team.

Make no mistake about it.   The role of pharmacists in cancer care is growing.   This is because of the expense of drugs and safety issues – 1) drug interactions with other drugs, over the counter medications, herbal medications, dietary supplements.  Many pharmacists have computer programs for tracking these interactions; 2) compliance issues – pharmacists are in a position to know if patients are filling their prescriptions  and may be of help in facilitating  access to these drugs or negotiating discounts.   A new specialty, board certified oncology pharmacists, now exists.  About 1% of the nation’s 250,000 pharmacists are now board certified in this specialty.   These new specialists are now much in demand in hospitals, cancer centers, oncology practices, and in nursing homes,   all of whom are trying to reduce costs and enhance effectiveness.  There is even a new journal The Journal of Oncology Pharmacy Practice.

The Triple Aim

The goals of managed cancer care are called “the triple aim”- to create a positive patient experience, to optimize outcomes, and to reduce costs.  To accomplish these aims, the cancer community and payers will increase guidelines and protocols, focus on evidence based care, utilize case management techniques, aggressively manage drug sales prices, aggressively contract for best prices and best practices, call for more appropriate uses of imaging and radiation modalities, and explore the possibilities of bundled care for specific cancers and episodes of care.

Tweet:  The effect of Obamacare on treatment of cancer patients has been profound because it focues on economic rather than clinical issues.

 

Will Obamacare Unravel Before January 1, 2014 When It Is Scheduled  To Take Full Effect

1.      To separate the threads  of (a fabric, rope, etc)

2.      To free from complications; to make plain or simple; to solve: To unravel a mystery

3.      To become unraveled.

Definition of Unravel

It depends…

On how you define unravel

With whom you want to cavil

On whom you dare to ask

On your ideological mask

On the company in which you travel.

On unsettling actuarial surprises

Predicting double-digit premium rises

On 1 to 2 year delays for small firms

Already struggling to come to terms.

With uncertainties and faulty surmises.

On how many Democrats face the hard facts,

Of things like the medical device revenues tax,

When the tax hurts the economies of their states,

It give them guts to swim across the party straits,

And to give certain Obamacare provisions the ax.

 

On Obamacare's  media campaign

As it tries reform goodies to explain

And to make it plain and clear

That its benefits are no small beer

That with it better care you will obtain.

On Obama's success in convincing  the electorate

That the law is essentially a government protectorate

That its implementation and your health rests on your vote

To show on November 2014  we will all be  in the same boat

If the law is carried out under a Democratic directorate.

 

For different points of view on Obamacare unraveling, see the following

1.      “The Unraveling of Obamacare”, Forbes, October 2, 2012

 

2.      “Obamacare Unraveling”, John Lotts Website, February 13, 2013

 

3.      “Obamacare Starts to Unravel”, Wall Street Journal, October 18, 2011

 

4.      “Obamacare Unravelijng”, www.gop.com, October 17, 2011

 

5.      “Obamacare Is Unraveling”, www.fromfourmOctober 17, 2001

6.      “Could String of Lawsuits Unravel Obamacare”, Politics: CBN, January 9, 2013

7.      “Obamacare’s Great Unraveling”, National Review, October 17, 2011

 

8.      “Democrats Faced with Reality- The Unraveling of Obamacare”, ARRA News Service, March 30, 2013

Tweet:  The uncertaines of Obamacare and its effect on the economy may cause it to unravel before it is fully implemented on January 1, 2014.