Tuesday, July 31, 2012

Is Physician Unhappiness Important, and Are Physicians’Saying They Will  Leave Practice an Idle Threat?
Idle threat,  noun,  deficient threat, empty threat, harmless threat, ineffectual threat, meaningless threat, menacing, mere notice, mere talking, mere warning, only words, subtle intimidation, testing, trial balloon, veiled threat

Burton's Legal Thesaurus, by William C. Burton, 2007

 July 31, 2012 – A July 27 piece by John Commins in Health Leaders Media, opens:
“Blaming low compensation and the hall healthcare reform, 34% of physicians say they plan to leave the practice of medicine over the next decade, according to new National survey.

John Commins,  "Of of Three Doctors Say They Will leave Medicine,' Healthleaders Media, July 27, 2012)

July 31, 2012 -  Is physician unhappiness important?Are physician complaints of low pay and reform hassles justified? Are threats to leave practice just idle threats, or just a form of whining by spoiled doctors accustomed to independence  and high pay?  Are repeated  physician surveys indicating doctors plan to leave  practices simply an ideal threat, designed to win sympathy from patients and voters? Will physicians follow through?   Where can they go and how would they make money commensurate with what they make now?
I’m biased, but I think;
1)       Physician unhappiness is important, especially when you consider doctors spend 11 to 15 years getting where they are, at considerable expense and delaying gratifications.  When the joy of practice is gone,  why continue doing something you have come dislike?
2)      Physician compensation has been flat for a decade with expenses rising 3% to 5% per year.   And on surveys doctors say hassles drive up expenses ever further, and take up to 1/3 of their time.
3)      Are doctor saying they wii leave practice  ideal threats? Maybe not, many have nowhere else to go outside of medicine, and they have those educational debts of up to $250.000 to pay.  But they are abandoning private practice in record numbers, and  hospitals now own about ½ of physician practices.    Add to this to the fact,  that less than ½ of doctors now accept Medicaid patients and about 1/3 now longer take new Medicare patients, and you will realize the threat to leave their current practices is not idle.  It is real, and it is why the physician shortage, now estimated at 62,000 and projected to be 125,000 in ten years, is growing.
4)       Where can they got make money matching what they make now?   They can become medical directors, administrators, or leaders of health care organizations?  They can into medical related enterprises – such a pharmaceutical companies, medical device firms, or health care finance and management companies?  They can become entrepreneurs, creating start-ups, backed by venture capitalists and others. They drop out of practices  paid by 3rd parties, including Medicare and Medicaid, and form direct pay or concierge practices.
Let me conclude with a few details from the latest physician survey to put some meat on the bones. Jackson Heathcare, an Atlanta-base recruiting form, surveyed 2,218 phyicians – 16% said they will, or are strongly considering leaving practice in 2012, and 34% said they would be gone by 2022.  Of those saying they would leave in 2012, 55% were under 55 years of age. They said they were not retiring,  They were quitting. Among the entire sample,   56% cited economic reasons for departing medicine, 51% complained of health reform.
Specialists most inclined to leave were: oncologists and hematologists, 57%. otolaryngologists 49%, general surgeons 49%, cardiologists 45%, and urologists 42%.  Why  no primary care groups – family physicians, generalist internists, and pediatricians – on the list?
 I do not know.  Perhaps it is because primary care physicians could not afford to leave, perhaps it is  because the health law promises a 10% rise in primary care pay; perhaps it was because Obamacare is in the process of cutting specialist pay by 30% to 40%.
Tweet:  A doctor survey indicates 16% say they will leave medicine this year, 34% by 2022 because of low pay,  practice hassles, and health reform.

Monday, July 30, 2012

“V” Is For The "Victory" of “Value” over “Volume” – An Interview with a Venturesome Visionary

Whether is fled the visionary gleam?
Where is it now, the glory and the dream?
William Wordworth (1770-1850), Intimations of Immortality
July 30, 2012
Q: I understand you have future dream, a visionary gleam in your eye.
A:  That’s absolutely, irrevocably true.  My dream is based on fact, not fiction.
Q: What is your dream?
A:  My dream  is that  it will be clinical  “value,” not clinical“volume,” that will be paid for. It will not be the number of patients passing througgh the health care tollgates but what happens to them - how much their health improves and their death rates drop.

 I call my dream  “Value-Based Purchasing,” or "VBP, " “Evidence-Based Purchasing ,” or “EVP,” or “moving from volume to value.”  Everything in medicine, I dream, will  be “evidence-based.”  Reason, not personal relationships,  will be in season. That’s my dream.
Q: You must be frustrated.  It must be a nightmare out there for you now.  After all, hospitals and medical groups still recruit physicians looking for “productivity,” the volume of patients seen or services provided, not the value of those services or the outcomes.- to pad their bottom lines.   

Fee-for-service remains the lay of the land.  Volume of specific  current clinical actions is what payers pay for, not the bang for the buck or  ultimate outcomes down the road.  An alternative payment model has yet to be developed.  It’s hard to code a dream. It's easy to code a visit, a procedure, or a visit.
A:  I know.  But in the end, data will be our salvation.  It will trump frustration.   Fellow reformers share my vision and my dream.  We know it will be prevention, not treatment,   processes and outcomes, not what patients and doctors want and are currently paid for, that will  count.
Q:  Do you tolerate any variance from your dream of the scheme of things?
A: No, none.
Q:   Why not?
A: Because human-based “Fee-For-Service” drove us into this mess. VBP and EVP is the way out of the FFS morass.  “Fee-For-Service” ought to be called “Fee-for-Nervous.”  It is nothing but nervous people looking for emotional rather than factual care.
Q:  But people want human “service” not  impersonal  “data,” do they not?
A:   Exactly. That’s the problem.  We can’t yet put a number on data-based  services. So providers provide a greater and greater number of “services.” That is a vapid, vacuous view of the world.  It is not scientific, and it is not value- based.
Q:  But  it is very human, is it not?
A:   Not really.  It is based on the past, the Art of Medicine,  not the Science of Medicine.  It doesn't compute. In humanity patients and physicians may trust, we scientific reformers  trust only Data.
Q:  What is your message?
A: Verily, verily, I say unto you. “V” is for “Victory”of “Value over Volume, the vanquishing of subjectivity by the forces of objectivity.   Ours will be the final dictum. Fee-for-service will be the victim.   Hard data, not human errata, will be the rule.

Source:  Jordan M. VanLare and Patrick H. Conway, "Value-Based Purchasing - National Programs to Move from Volume to Value," New England Journal of Medicine, July 26, 2012
Tweet: In the future,  payers will pay for value, evidence-based services and outcomes,  rather than fee-for-service, so say value-evidence-based visionaries.

Sunday, July 29, 2012

Implications of the Present and Future Doctor Shortage
Experts describe a doctor shortage as an “invisible problem.” Patients still get care, but the process is often slow and difficult.
Annie Lowrey and Robert Pear, “Doctor Shortage Likely to Worsen with Health Law,” New York Times,  July 28, 2012

July 29, 2012 -  Well, I see the mainstream media  is finally beginning to acknowledge one of the glaring deficiencies  of the health care law – a present and future doctor shortage. 
I’ve been repeatedly predicting that a political crisis will become manifest about 2015 – when  30 million more Medicaid and underinsured  and the first wave of 78 million Medicare eligible baby boomers  start looking for doctors and can’t find any.
How could this be in an affluent nation in which even primary care doctors make an average of $200,000, specialists twice that much, and all doctors are gainfully employed? 
I shall tell you why.  
Medicine isn’t fun anymore. And it isn't  particularly profitable either.  MBAs often make more money over the long run ,  spend years less acquiring an education, have far less  educational debt, and run a far less risk of being sued.  
Furthermore,  multiple surveys show massive demoralization among doctors (see "Health Reform and the Decline of Private Practice,"  The Physicians Foundation in survey conducted by Merritt Hawkins, 2010). Pessimism is equally shared among young and mid-career physicians (Aubrey Westkee, “Young Physicians Less Optimistic Due to Health Reform,” Physician Practice, April 28, 2012).
Why  should you become a doctor if the following factors are rendering medicine less attractive as a career (Testimony of  Mark Smith, president of Merritt Hawkins, the nation’s largest physician recruiting firm before House of  Representatives, July 19, 2012)?
  1. Flat or declining reimbursement
  2. Growing regulatory and administrative paperwork
  3. Malpractice insurance costs
  4. The implementation of information technology
  5. Medical education debts
  6. The effects of health reform
The New York Times article is not helpful in suggesting how to alleviate the doctors shortage. After saying the U.S.. is likely to be 120,000 doctors short by 2025, the article  says,
Health experts, including many who support the law, say there is little that the government or the medical profession will be able to do to close the gap by 2014, when the law begins extending coverage to about 30 million Americans. It typically takes a decade to train a doctor. “
The articles goes on to comment that by 2012, there will be 73.4  million Americans on Medicare compared to 50.7 million today.  Population growth,  aging, and more health-law induced-Medicaid recipients will futher spur demand.
What to do?   Here are a few modest suggestions, which will never hear form the New York Times,  an Obamacare backer.
·         Advance age of Medicare entry to 67, may even to 70, over course of next 5 years.
·         Means test for Medicare.
·         Offer Medicare and Medicaid recipients optional private voucher plans.
·         Let states operate their own Medicaid plans subject to certain federal oversight provisions.
·         Repeal and replace Obamacare.
·         Make cost-sharing by patients more evident by expanding health savings accounts linked to high deductible plans.
·         Sensitive physicians to health costs by having them neogotiate with HSA-cost-sensitized patients.
·         Enhance cost-competition between health plans by making them bid for nationsl  business across state lines.
·         Let Americans have the same benefits offered to  government employees and national politicians on government employee health benefit plans
·         Lower premiums for individuals and the self-employees by giving  them  the same tax benefits enjoyed by corporations.

.    Pass national tort reform bill.
Tweet:  Expanding coverage under health law will speed doctor shortages and will make it difficult for people to find doctors.

Saturday, July 28, 2012

Behavioral (Cultural ) Change – The Biggest, Rarely Acknowledged,  Challenge of Health Reform

Physics does not change the world it studies. And no science of behavior can change the essential nature of man, even though both sciences yield technologies with a vast power to manipulate their subject matters.
Burrhus Frederic Skinner (1904-1990), Cumulative Record (1972)
July 27, 2012 -  Health reform,  however well-intentioned, seldom changes the fundamental behavioral patterns of man  These  patterns are ingrained over a life-time and are the product of our culture and our training.  Nor does reform reverse cumulative disease processes,  which are embedded in our organs, our nervous systems, and are derived from our behavioral patterns.   That is why some reform measures designed  to alter clinical behaviors or  outcomes are destined to either fail or have little impact.
Three of these measures come to mind.
One, failure of pay for performance programs for physicians to improve outcomes.   It is thought if we only incentivize physicians to meet quality standards by paying them for performance , they will perform better.   Yet  studies here and in the United Kingdom show P-4-P does little if anything to enhance performance.   In euphemistic academic circles,  this is known as the “null effect” (Jha AK, et al, “The Long-Term Effect of Premier Pay for Performance on Patient Outcomes, “ NEJM, 2012: 366: 1602-1615).  The article refers  to the Medicare Premier Hospital Quality Incentive Demontration project, which offers bonuses of 1% and 2% to hospitals reaching th top tier of  quality indicators.  The outcome changes were insignificant. The explanation for this failure is that the failure to improve outcomes “suggests that we have not yet learned to struture pay-for - performance programs.”  Nothing is said of the reality  that maybe hospitals and physicians everywhere seek to practice good medicine, regardless of financial incentives, and they are doing the best they can and the best that can be expected in most clinical circumstances.
Two,  failure of federal punishments of hospitals to reduce 30-day hospital  readmissions. The rationale here is that doctors and hospitals somehow fail to treat hospitalized patients appropriately,  fail to teat their basic disease outcomes correctly in the hospital,  do not give them proper instructions on what do once they return home, do not give them proper support in a home-bound environment, or  somehow fail to treat or improve their disease condition while hospitalized.   It is seldom, if ever mentioned  that chronic conditions, such as heart failure,  culminate from a variety of causes – genetic, environmental, social deprivation, and past behaviors that are beyond the reach of hospitals and doctors.   The typical patient may spend a few hours to several weeks with a doctor or hospital, but they have spent a lifetime developing what ails them.  As someone has observed,  “We dig our graves with our own teeth.”  And “ We fail to use our two legs for what they were intended,  to move us and keep the blood circulating.”   Furthermore,  chronically ill patients, once home , tend to return to the behaviors and habits of a lifetime.
Three,   there is a national reform movement afoot, known as “Value-based Purchasing - National Programs To Move from Volume to Value”(see July 26 NEJM article).  The theory is that if only we could get hospitals and doctors to change their behaviors and modify their outlooks by concentrating on patient safety, patient and care-giver centered experience and outcomes, coordinating care,  improving clinical  process meaures, concentrating on populution and commuintiy heath, and developing efficiency and cost reduction, we could achieve better health and better care.  In short, if only hospitals and physicians could change their past behavior could make decisions based on “value,” i.e, “quality and efficiency as perceived by top=down reformers,  all would be well. 

Tweet:   Changing the medical culture by altering hospital and physician behaviors through  financial incentives is an “iffy” proposition and often fails to improve outcomes.

Friday, July 27, 2012

Enjoy the interview with DPMA Member Dr. Richard Reece!

By Leslie Johnston,  Membership Director, Doctor Patient Medical Association
July 27, 2012 - Reading Dr. Richard Reece’s latest book, The Health Reform Maze: A Blueprint for Physician Practices, was an encounter with common sense.
Donald J. Palmisano, MD, JD, FACS,  former president of American Medical Association,  said of the book, “It‘s a must read collection of essays that gives the good, the bad, and the ugly of the new healthcare law, PPACA”
Dr. Reece has written 2350 blogs, 1500 tweets,  and 11 books on freedom in medicine. You can read his blogs at medinnovationblog.blogspot.com.
Dr. Reece is a renowned physician author. He has written a myriad of articles spanning the vast terrain of medicine. His topics cover everything from, “Why Doctors Don’t Like Electronic Health Records,” to “Common Medicare Scams.”
Dr. Reece is a retired pathologist but continues to invest in patients through his writings and speaking engagements. He resides today with his lovely wife of 50 years in Connecticut. We are fortunate and happy to engage him today on preserving liberty for doctors and patients in health care.
Enjoy this interview with DPMA Member Dr. Richard Reece!
Dr. Richard Reece on freedom in medicine, authenticity in health care policy, and why it is important to preserve our health care liberties.
Q: What are you “for” and”against”?
A: I am “for” health reform, with better outcomes and lower costs.

I am “for” universal tax credits for individuals and corporate employees. 

I am “for” national marketing and choice of employee health benefit plans now enjoyed by government employees.

I am “for” marketing of plans across state lines. I am “for” widespread implementation of health savings accounts linked to high deductible plans.

I am “for” direct-cash and concierge practices.  I am “for” moving the age of Medicare eligibility to 67, means testing for Medicare, Medicare vouchers, Medicaid block grants for the states – whatever it takes to preserve, save, and sustain these vital programs for future generations.
I am “against” Obamacare.  It should be repealed and replaced as unworkable and prohibitively expensive.  It is full of good intentions, but as Samuel Johanson (1707-1784) observed, "The road to hell is paved with good intentions." And I would add, "unforeseen and adverse conequences."
I do not regard “Obamacare” as a pejorative, partisan, or dismissive term.  The President himself embraces the term because, he says, it shows he “cares." Besides, “Obamacare” embodies his governing philosophy, which is “trickle-down government.”
Q:   What does “freedom” in medicine mean to you?
A:  “Freedom” means being able to choose your own doctor and to have your doctor choose what is best for you. These choices should be personal, patient-centered, commonsensical, and cost-effective.
The coming election is about choosing between: one, individual freedoms, choice and enterprise, and two, collectivism, government control, and economic security. It is not, in my opinion, about “social justice.” That comes when the economic prosperity tide lifts  all boats.
Q:  You call the President’s Health Care Bill a “Raw Deal” for doctors. Why?
A:  It’s a “raw deal” because over the course of 10 years, it cuts doctors’ income to the level of Medicaid (now 56% of private pay), allows an unelected payment commission board to set doctor pay, controls what doctors can order for patients and what government will pay, and bases reimbursement on “value based evidence” of patient outcomes rather than on doctor-patient based decisions and interactions.  It is about remote bureaucrats and managers making decisions rather than doctors and patients at the point of care.
Q:  What does “authenticity” mean, and how does that play in the pieces you write for your blog and the media?
A: My dictionary defines, “authenticity” as the truth or reality.  Frankly, I do not think government experts know what constitutes truth or reality on the ground in doctors’ offices or hospital corridors.   These experts advocate data-dictated care.   They see data as a Holy Grail. They are fond of smugly saying, “In God we trust, all others use data.”  The health system would be better served if these experts spent more time in doctors’ offices, listening and observing and less time in front of their computers, crunching numbers.
Q: Are there any surprises regarding the responses you receive on your blog posts and writing?
A:  No, people stand where they sit, and they rarely change their mindsets or political positions.
Those on the left think of government as custodian and protector against private abuses. They believe physicians make decisions in their own self-interests rather than in in the patients’ best interests. Further, they do not believe patients are sufficiently intelligent or informed enough to make health care decisions.   They believe health care ought to be a “right” and “free” entitlement.  As Margaret Thatcher observed, “The only problem with socialism is sooner or later you run out of other peoples' money.” Obamacare may not be socialism. But it is left-center  stab at it in a right center country.
Those of the right think medical professionals should be trusted to do what they spent 12 to 15 years learning to do, and health consumers are smart people, perfectly capable of making health decisions in their own best interests, in concert with their doctors.
Q: How do you see PPACA directly impacting the personal liberties of physicians and patients?
A:  The PPACA impacts physicians by compelling them to comply with federal regulations, to prescribe electronically, to install electronic health records, to accept lower federal reimbursement for Medicaid and Medicare patients.  It impacts patients by making them enroll in government-approved plans, by limiting the procedures and tests they can receive,   potentially by rationing care, and raising premiums and taxes. . 
Q:  If you had a crystal ball, and the President’s Health Care Bill is not overturned-what are the most significant changes you foresee in health care over the next ten years?
A:  I do not have a crystal ball, although it is sometimes said of pathologists that they know everything but it is too late.   For doctors, I foresee a steady decline of private practice, particularly of solo and small groups, an explosion of regulations, an increase in the load of Medicare and Medicaid patients, and a herding of doctors into salaried employment in consolidated and integrated health systems with enough electronic and administrative infrastructures to deal with federal regulations.  For patients, I foresee increased premiums, limiting of choice to government-endorsed health plans, long waiting lines to see a doctor, more care in community health plans and safety net institutions, and restricted access to high tech care by specialists.
Q;   Does it take a measure of personal courage to publish your views on health care?
A:  No, I am an independent thinker, beholden to no one.  I am of an age where I say what I think, based on what I observe and on the historical record.
Q: Who or what inspires you as you write about health care?
A:   I believe in the American ideals of individualism, free enterprise, hard work, and choice. I believe these ideals apply to medicine as well as the economy as a whole.
Q: Why did you join the DPMA?
A: to preserve and to articulate those ideals.
Q:  One last question.  Why is the PPACA so controversial and confusing?
A:  That’s easy. 
 It is controversial because it is the most comprehensive piece of social legislation ever attempted.  It covers the whole health care waterfront:  coverage, quality and efficiency, prevention and wellness,,the health care workforce, fraud and abuse, long term care, biopharmaceuticals,  medical devices, neglect of the poor and elderly. 
It is controversial because it calls  for an expenditure of roughly  $2 trillion over  the next 12 years with new  taxes of over $500 billion.  It is controversial because it affects every American.  Yet it passed  without a single Republican vote. That has never happened in the history of the Republic.  That poisoned the political process.  
It is controversial  on the physician side of the equation because it calls for  flat or declining reimbursement, growing regulatory and administrative paperwork, no relief from malpractice costs,  forced implementation of expensive information technologies,  no tort reform, no relief from medical education debts, and health reform’s adverse consequences.
 It is confusing no one understands its high costs and adverse effects,   These are buried in a 2700 page bill written in federal jargon which no one has read or understood in its entirety. As Jonathan Oberlander remarked in a December 9, 2010, New England Journal of Medicine article, “The law is not a single program. It  is a collection of mandates, public insurance expansions, and regulations that affect different groups of Americans in different ways at different times.” It is a toxic health care cocktail  concocted by politicians far removed from the clinical scene.
As Nancy Pelosi famously said, “We’ll  have to pass it to see what’s in it.”  We are just beginning to see what’s in it, and we do not like what we see.


Thursday, July 26, 2012

Staying Away from Doctors – The New Cost-Containment Movement 

An apple a day keeps the doctor away.
19th Century Aphorism
July 26, 2012 -  Go to Google. Click  on “Staying away from doctors,"  and you will find a host of reasons to stay away from doctors to contain health costs.   These include not only an apple a day, two bananas a day,  five fruits and vegetables a day,  more exercise, fewer prescription drugs, no cigarettes, and good health.   These are commonsensical suggestions, and I applaud them.
If you feel fine,  have no symptoms,  and enjoy good health, stay away from doctors.    Doctors , it is said,  will order unnecessary tests,  will cause unnecessary anxiety and alarm, and may even casue  harm you by pursuing borderline abnormal tests.
In a New York Times blog today, "Too Much Medical Care?". Tara Parker-Pope, a widely respected health care journalist,  lays out that “too much medical care” scenario.  The U.S. spends 50% more on health  care than any other industrialized because of excess health care spending on doctors and hospitals. 
Parker-Pope cites these figures causing high costs
  • Unnecessary Services = $210 billion (27.4%)
  • Inefficiently Delivered Services = 130 billion (17.0%)
  • Excess Administrative Costs = 190 billion (24.8%)
  • Prices that are Too High = 105 billion (13.7%)
  • Missed Prevention Opportunities = 55 billion (7.2%)
  • Fraud = $75 billion (9.8%)
Note that unnecessary services,  inefficient delivery,  high administrative costs, and prices too high  together account for almost 90 % of medical costs. Presumably many of these costs could be done away with if patients did not see the doctor at all.  
I suppose that is so.   Not mentioned in her analysis are defensive medicine engendered by physician concern over malpractice,  patients going to doctors for minor concerns such as URIs or minor backache and expecting antibiotics and MRIs, expenses secondary to private and public bureaucratic demands for documentation,  the lure of “free” care covered by private and public third parties,  and the high expectations of patients desiring to have everything possible done that can be done.
On the “missed prevention opportunitities,” how do you tell patients to stay away from doctors when the patient wants a physical to check on the state of their health,  when they want to know what their cholesterol or blood glucoes is,  when they seek drugs for depression or anxiety or hypertension, when they want a mammogram to rule out breast cancer, or when they want an antibiotic for a viral infection?
Our reporter presents the case of her elementary school daughter’s painful ankle. The daughter  sees multiple specialists ( a pediatrician, a sport medicine doctor, an eye specialist,  a pediatric rheumatologist, and a pediatric orthopedic surgeon.),  has an exhaustive workup, including at least three MRIs and multiple blood tests, and ends with a  pain regimen that solves her daughter’s problems.
Would I be out of line if I suggested that 3rd party intervention might be responsible for driving up many of these costs?   This intervention creates the mindset that in the end someone else pays, not the patient, and desensitizes patients and doctors alike to the true cost of care, and in the process creates a private and public bureaucracies to monitor and measure care and build unrealistic expectations of what that care can accomplish.
Tweet:  Lately a movement has been growing telling healthy patients or those with minor ailments to stay away from doctors to save money.

Wednesday, July 25, 2012

Condescension, Prosperity, and Health Reform

There is nothing more likely to betray a man into absurdity than condescension.
Samuel Johnson(1709-1784), in Boswell’s Life of Johnson
July 25, 2012 – When I lived in Minnesota,  I would occasionally hear Minnesotans sniff  and remark condescendlingly, “North Dakota is not the end of the earth, but you can see it from there.”
I wonder what the Minnesotans are saying now.  North Dakota is the second leading state in energy production after Texas, has the nation’s lowest unemployment rate at 3.8%,  and is undergoing an unprecedented boom.    All of this is due to hydraulic fracking with release of natural gas and oil from underground shale.   
North Dakota may not be the end of the Earth anymore.   Instead, It may mark  the beginning of American’s new prosperity with America meeting its own energy needs without relying on the Middle East.   North Dakota is even generating a budget surplus , which will relieve the pressure of Medicaid on its state budget.  Indeed, with generalized prosperity, the number of Medicaid recipients, numbering 108,000 in North Dakota may even drop.
One of President John Kennedy’s more famous quotes is “ A rising tide lifts all boats.”  He was referring to the general economy condition of the country.  Some have interpreted this to mean President Kennedy was espousing the “trickle-down economy, “ meaning if you lower taxes on the rich,  riches  will trickle down  to the middle class, and everyone will benefit. There is some ideological dispute about what Kennedy meant,  especially among those on the left.

But there is no dispute that that the current president,  Barack Obama,  advocates "trickle-down government.“  He condescendly believes  most good things flow from government, that government provides t infrastructure that greases the wheels of prosperity,   that government boosts the health of the nation,  and that government is responsible for restributing the wealth and profits of the private sector.    In Obama's  mind, there may be no such thing as the self-made man who built his wealth and personal initiative,   hard work , and imaginative ideas.
In President Obama’s rhetoric and his policies,    a condescending tone pervades his attitude  towards the private sector and  state gvernments.  Obama  attacks the states on Medicaid policy. He does not not trust them to cover their poor through block grants. He seeks to force  upon them exchanges run by the federal government.   Obama would impose increased taxes on small businesses making more than $250,000.
Obama seems to believe that energy policy should be dictated from above, that the future belongs to wind, solar, and fast trains and that fossil fuels and the Keystone pipeline will soon be history.  
Tell that  and sell that  politically to boom states like North Dakota, to energy-rich states like Texas, Oklahoma, Wyoming, and even Coal-rich West Virginia, Ohio, and Pennsylvania.    Tell it and sell it to 270 million Americans who own their own cars, and to the 70% who drive to work in their own vehicles,  and to state governors who cannot stay within budget because of unemployment, stagnant economies, and sky-rocketing  Medicaid populations. Oil is the fuel that drives America and will be for a far as the mind can reach and the eye can see.
Tweet: America is undergoing an energy and economic boom with relief on state budgets and Medicaid costs  in states producing oil and gas from fracking.

Tuesday, July 24, 2012

Blasphemous Thoughts on Health Costs

Great truths begin as blasphemies.
George Bernard Shaw(1856-1950)
July 24, 2012 -  I seek truths in these blogs.   Unfortunately, sometimes what I say comes out as blasphemies. 
To wit.
·         The U.S. health system problems are not due to its failures but to its successes, which lead to excesses.  Speak to enough Americans, and you will quickly realize that it is common knowledge that joint replacements relief pain and restore function,  coronary stents and bypasses save and prolong lives,  cataract and Lasix procedures restore normal visions, and  access to specialists who perform these procedures is quick and easy in the U.S.  News of these positive results spread rapidly among friends and across the community.   It is sad to say, but , because of their effectiveness,  these surgical treatments are among the most costly for Medicare.  Nothing succeeds like success in relieving pain, saving lives, and restoring vision, but at the same time, nothing exceeds like excess demand in driving up costs.   Specialists are very good at what they do,  which is why more aging  consumers go to them to get  things done that have worked so well for others.

Blasephemy Number One -  Consumers with high expectations of success, learned from friends, relatives, and neighbors,  not specialists, drive demand for high tech surgeries.

·         The best hope and only proven method so are for containing costs are health savings accounts and their variants tied to high deductible plans.    Some 15  million to 18 million  Americans now avail themselves of HSAs, employees know HSA premiums are lower, and  their employees know HSAs save money by as much as 30% over traditional HMOs and PPOs.   Why are HSAs blasphemous?  Because they go against core liberal  beliefs that health care is a “right” for all, not just HSA holders; that health care ought to be a “free” entitlement, paid for by government using other peoples money; and consumers, and the general public, are not smart enough  and do not possess enough government-generated data to make intelligent  decisions,  nor, for that matter, are physicians to be trusted to make decisions in the patients’ interests rather than their own self-interest.  Consumer-cost sharing, in other words, violates the principles of “trickle-down government, “ which holds that only paternalistic government has the wherewithal, expertise,  and compassion to decide what is best for you.  Never mind that HSAs grew by 18% in 2011,  their results satisfy employers and HSA-holders, and HSAs save money. In Indiana, more than 70% of state employees chose HSAs over traditional plans,  97% expressed satisfaction with the plans,  and saved the state over $20 million.The best hope for the U.S, to contain health care costs is to have consumers share in tax-advantage health savings accounts with money saved set aside for retirement.
Blapshemy Number Two -  Consumers, sensitized to costs by tax-advantaged health savings accounts,   contain costs because they are better judges of what is needed for their health and future retirement needs than federal officials.
Tweet:  Health costs soar because of effective treatment of  certain conditions: health savings accounts offer promise in containing these costs.