Wednesday, October 31, 2012

Systole and Diastole of Election: Goverment  Spending Vs. Market Discipline
Once more, in the great systole and diastole of history, an age of freedom ended and an age of discipline began.
Will Durant (1885-1981 , Caesar and Christ (1944)
October 31, 2012 -   The election is 6 days away.   The central choice is  in health reform is between  more government spending vs. market discipline.
An October 27 New York Times editorial  “Barack Obama for Re-Election” sums up the case for more government spending.  
“Allowing children under 26 to stay on their parents’ policies; lower drug costs for people on Medicare who are heavy users of prescription drugs; free immunizations, mammograms and contraceptives; a ban on lifetime limits on insurance payments. Insurance companies cannot deny coverage to children with pre-existing conditions. Starting in 2014, insurers must accept all applicants. Once fully in effect, the new law would start to control health care costs. “
The main problems with line of reasoning is that since Obamacare” enactment in March 2010:
·         Health care premiums have soared by $2500 per family   
·         Businesses have postponed hiring because of uncertainties of Obamacare costs 

·         Estimates of its costs  have grown from $900 billion to $2.6 trillion

·          Employers have dropped up to 20 million from health coverage 

·         The ACA   remains unpopular with the public which favor its repeal by 54% to 39% 

·         And the GOP has further neutralized its appeal by  maintaining that Obama cut $716 billion from Medicare to fund Obamacare.
To complicate matters,  the public is schizophrenic  about Obamacare.    The public disfavors Obamacare as a whole.  According to Kaiser Health News,  there are those who like the law,  those who understand it, and those who want to repeal it.  A nationwide survey, conducted between 2010 and 2012, of 2000 people  indicated the following when participants  were given 18 statements about the law and asked to judge their correctness. For example,  80% knew the law allowed young people to stay on the parents’ policies under age 26 and that companies with more than 50 workers were required to offer coverage, but beyond those two provisions,  few participants were able to judge  any other provision with any certaintyas true or false.

Why this lack of understanding?   The first reason may be that reworking 1/6 of the complex health care economy is a matter of daunting complexity that effects different Americans in different ways.  A second reason may be that so far in the  nearly 3 years after its implementation, less than 30  million of our population of 310 million has so far been directly impacted by the Affordable Care Act.  A third reason may be that the two political parties spins its impacts differently.  A fourth reason,  as articulated by Jonathon Oberlander, an Obama supporter, in “Beyond Repeal – The Future of Health Reform,” New England Journal of Medicine, December 9, 2010, it that “The law is not a single program.  It is a collection of mandates, public insurance expansions, and regulation  that affect different groups of Americans  in different ways at different times.”

Tweet:  Health reform resembles the systole and diastole of the human heart, systole being more government spending,  diastole being market discipline.

Tuesday, October 30, 2012

Notable and Quotable: Obamacare Is Even More Unpopular Now than in 2010

Wall Street Journal blog, By Jeffry H. Anderson.

October 30, 2012

Preface:    Since I started this blog in November 2006, I have often criticized Obamacare and pointed to its unpopularity Among the American public.  The article below confirms my reading of the political tea leaves.  How big a role this unpopularity will not be known until the exit polls after the election are evaluated.   In the meantime,  Romney might be smart to repeat his pledge to  start to repeal Obamacare on the day he takes office.

“According to newly released polling from Rasmussen Reports, by a margin of 15 percentage points (54 to 39 percent), likely voters now support the repeal of President Obama’s centerpiece legislation. In the first three polls taken in the wake of the House’s passage of Obamacare (on March 21, 2010), Rasmussen showed that likely voters then favored repeal by margins of 13 points (55 to 42 percent), 12 points (54 to 42 percent), and 12 points (54 to 42 percent). Cementing Obamacare would be the principal focus of Obama’s second term.”
“The repeal of Obamacare is now supported by men (by 24 points), women (by 7 points), voters between the ages of 40 and 64 (by 22 points), seniors (by 32 points — and better than 2-to-1), Republicans (by 75 points — and better than 7-to-1), independents (by 9 points), those who make less than $20,000 annually (by 15 points), those who make between $20,000 and $40,000 (by 18 points), those who make between $40,000 and $60,000 (by 12 points), those who make between $60,000 and $75,000 (by 35 points — and better than 2-to-1), those who make between $75,000 and $100,000 (by 12 points), those who make $100,000 or more (by 3 points), those who work for private companies (by 6 points), those who are entrepreneurs (by 28 points), those who are retired (by 30 points), those who didn’t graduate from high school (by 49 points — and better than 3-to-1), those who graduated from high school but haven’t attended college (by 51 points — and better than 2-to-1), those who went to college but haven’t graduated (by 29 points), and those who graduated from college but haven’t attended graduate school (by 8 points).”
“The repeal of Obamacare is opposed by voters under the age of 40 (by 4 points), Democrats (by 40 points — and better than 2-to-1), government employees (by 3 points), and those who have attended graduate school (by 10 points) — in other words, by Obama’s core constituency.”
“The more often Mitt Romney mentions Obamacare in these closing days (on the stump and especially in TV ads), the more likely he is to become the next president of the United States”
Tweet:  Obamacare is more unpopular than ever by a margin of 15%, particularly among Republicans, entreprenuers,  retirees, and those who aren't college graduates.


Storm Warning
Blow, winds, and crack your cheeks!
Rage! Blow!
You cataracts and hurricanes, spout
Till you have drenched our steeples,
Drown’d our weathercocks!
Shakespeare (1564-161), King Lear

October 30, 2012
Do not delude yourself, Miss Sandy Storm.
You are not a perfect three part storm.
You don’t the coming election transform.


Roar, tropical hurricane winds, roar.
The national budget deficit will still soar.

Howl,  Nor’ Easter gales, howl.
Political critics will still cry foul.

Rain & snow, Canadian cold front, rain & snow.
Inland and in the mountains, to polls voters will  go.

Surge & flood , you three merged storms,  surge & flood
The election issues you will not purge or end bad blood.

Cut the power, turn off the lights, cut the power.
You cannot the American electorate disempower.  

Tweet: Now that Miss Sandy Storm has done its damnest, life and the election will go on & the dampness will recede.




Monday, October 29, 2012

The Rising Tide of Mobile Medical Device Innovations, Sparked by Mobile IPhone, Tablet Computers, and Wireless Sensors
You can never tell what innovators will do when left to their own devices.
October 29, 2012 -   Hold your breathe.  We are about to enter a fast-paced  new chapter on the use of  Iphone generated ,  wireless sensors, tablet-transmitted  medical innovation.  Apple’s IPhone series started the stampede,   Samsung, Motoral , Amazon, Google, and Microsoft, which just introduced it Windows 8 device, are in the hunt. 
Where the wireless high-speed bandwagon will go, no one knows. But several things are certain.
The new devices and apps will allow:
·         Physicians to monitor  patients at a distance – for routine checkups, for  function of implanted or wearable devices,  for condition en route to the hospital whether  they be on stretchers or in emergency vehicles.
·         Patients to monitor themselves from home or work or during travel. At home or abroad.
·         Cardiologists to look directly into the heart  and to view its muscles, valves, muscles,  and rhythm.
·         Doctors to view images of MRIs,  CT scans, and electorcardiograms
One another note.  This is not the first time I have commented on mobile devices, 
Here is a previous blog I wrote on the subject dated December 12, 2011

He who does not economize will agonize.

Confucius (551-479 B.C.)

Preface: Anthony Regalado, business editor of the MIT Press’ Technology Review ( sent me the following article, which will appear in Technology Review today.

The author of the article is Eric J. Topol, Chief Academic Officer of Scripps health. It is an important contribution to the health care innovation debate. Topol is also author of The reative Destruction of Medicine: How the Digital Revolution Will Create Better Health.
"Medicine Needs Frugal Innovation,"  Technology Review

“A low-cost pocket ultrasound device can see into the human heart. So why do so few doctors use it?”

“In the history of medical innovation, advances in technology have been inextricably linked to increases in cost. But we are at a unique moment in which the insular world of medicine is about to be penetrated by the remarkable digital infrastructure. Think about the cost of computing. Over the past two decades, cost has been relentlessly reduced while capacity and performance have dramatically increased. How and when can this trend reach the practice of medicine, where costs often go up with little real improvement?”

“Let's consider the icon of medicine—the stethoscope draped around the doctor's neck or in the pocket of a white coat. Invented by René Laënnec in 1816, the stethoscope didn't see routine use by the medical community for another 20 years. The lag in acceptance reflected the conservative nature of physicians, who objected to having to learn heart sounds and let an instrument get between their healing hands and the patient. “

“Now, nearly 200 years later, economic forces are greatly slowing the adoption of a powerful replacement for the stethoscope in cardiac medicine. Instead of listening to the heart of a patient, I can now watch it on a device no bigger than a cell phone—a high-resolution miniature ultrasound probe. In fact, in my clinic I have not used a stethoscope to examine a patient's heart for the past two years. “

“Why would I listen to the "lub-dub" of heart sounds when I can actually see everything relevant about the heart in real time? Exquisite ultrasound images of the heart muscle—showing its contraction, its thickness, the size of the chambers, the valves, the sac around the heart—can all be obtained within seconds as part of a routine physical examination. I can share and discuss the images with the patient as they are being acquired, put video recordings in the electronic medical record, and send them to the patient or referring physician. The up-front cost of the pocket ultrasound device is about $7,700, but there is no extra cost for an unlimited number of readings. “

“That makes these small devices a formidable challenge to business as usual in American health care. Each year in the United States more than 20 million echocardiograms (ultrasounds of the heart) are performed, and so are a similar number of abdominal and fetal ultrasound examinations. Each of these diagnostic procedures is done in a dedicated laboratory setting, either in the hospital or in a doctor's office, with expensive equipment—and a combined professional and technical charge of $1,000 to $2,000. The math is straightforward. If a pocket ultrasound device were incorporated into routine physical exams the same way we use a stethoscope, several billion dollars in unnecessary charges would be saved each year.”

Therein lies the rub—and the explanation for why many low-cost innovations are being held back in medicine. Those savings would represent a critical hit to revenue for doctors and hospitals. It's not just that doctors, like those who refused to use the stethoscope, are intrinsically conservative. The American health-care model of billing "medicine by the yard" creates economic disincentives to cost-saving technology. In contrast, pocket high-resolution ultrasound has been rapidly adopted and hailed as a breakthrough in countries such as India, China, and Brazil.”

“This represents just a single, simple example of how frugal innovation—the idea of coupling engineering creativity with lower costs—could be achieved if patient care in the United States were not determined by reimbursement rules. We now have wireless sensors that can help us diagnose sleep apnea by capturing all the relevant data for sleep studies—respiratory rate, oxygen saturation of the blood. The data can easily be captured for less than $100, right in a patient's home. But instead, the medical community keeps using $3,000-per-night hospital sleep labs to make the diagnosis.”

“I believe a great inflection is coming in medicine: advances in technology will finally help us override the reimbursement issue and topple the economic models that physicians, insurers, and hospitals still cling to. This moment will arrive as medicine is opened to the digital infrastructure of mobile wireless devices, pervasive connectivity, ever-expanding bandwidth, cloud and supercomputing power, and the Internet. “

“Superimposed on these digital capabilities are the ones specific to health care—genomic sequencing, biosensors, advanced imaging, and health information systems. It will all lead to what I call "high-definition man": a panoramic, granular profile of an individual's molecular biology, physiology, and anatomy.”

“Medicine, in short, has the potential for better technology at a much lower price, but don't look to the medical profession, government, or the life-sciences industry to make the change on its own. I believe the change will come when consumers demand it. The Arab Spring and the Occupy Wall Street movement have shown the influence of social networks as a way to express citizens' demands. Don't be surprised if health care is occupied next.

Fitting and Proper Close

It is altogether fitting and proper that I close with this perverse verse.

When with new technologies, you no longer need a stethoscope,

You can use new technologies as an endoscopic periscope,

To see with what diseases you must cope,

At the other end of the diagnostic rope.

Technologies, unfortunately, can be abused,

And simple human observations underused.

Tweet:   Small portable  devices – Iphones, computer tables, & wireless sensors- have  potential to transform medicine into a lower cost enterprise.

Sunday, October 28, 2012

Time Spent with Patients: A Doctor’s Most Important Function
Know thy time.
Peter F. Drucker (1909-2005), The Effective Executive (1966)
October 28, 2012 - Sometimes what’s important hits us like a thunderbolt right under our noses.
I had a farm in Minnesota, 30 miles from my suburban home. My wife and I spent my day off and weekends there. A farmer of Czech heritage, Ladislav Malecha, took care of the farm for us. We would rush to the farm, then hastily rush back to the city. One day the farmer said to us, “What’s the rush? What’s more important than spending time with me?”
What indeed? Human beings judge their value to other human beings by time spent with them. Spending time with the doctor is what impresses patients. It is why they came to see you. Nothing irritates patients more than sitting idly in the reception or exam room, waiting for you. No more important use of your time than spending your valuable time with patients. What’s more important?
Other doctors, smarter and more insightful than me, have brought the importance of time to me over the years.
·         In December 2006, I wrote a series of 20 posts on how to build patient trust. The first blog post in series contained this paragraph.
 Dr. Randall Oates, a family physician in Arkansas, for example, decided he would only see complex patients requiring a physician’s professional knowledge; he would delegate to staff all other patients being seen for other reasons. His decision made better use of his time and increased coding revenues."
Randall has since gone on to form an EHR company called SOAPware, which produces easy-to-use software that saves clinicians time.
·         In January 2010, I wrote a post with the title “Physicians Business Ideas for Practice Productivity: Why Not Let  Patients Enter Data””  The post chronicles the story of Allen Wenner, MD, of Columbian, South Carolina.  Wenner pioneered and developed software, consisting of patient-centered software consisting of patient-enterable clinical algorithms  wherein patient could enter their demographics, chief complaint, and history by answering simple “yes” or “no” questions.  The output was called the Instant Medical History. which saved the doctor 6- 8 minues of history-taking time with each patients.
·         In May 2010 in “Practice Interruptus: Those Invisible, Inevitable Interruptions,” I told the story of Wesley Curry, MD, a A California ER Physician.”  Curry said the computer was a big time interrupter.  He spend 2-3 hours each workday logging in, inputting, or requesting information, and logging out of 6 to 8 software programs that had become mandatory in the patient encounter. One program was for obtaining lab results, one for X-ray, one for discharge, one for recalling past charts, and so forth.  Each log-in or log-out required more time for getting through the various security screens which shut down the program if there was no activity  for a few minutes when the doctor is away seeing patients. Logging in or out takes at least 30 seconds to one minute for each program, and in aggregate takes a significant amount of time which could be used to see patients. These programs helped retrieve useful information and document  the encounter,  but Curry  asserted, had little value  in creating real time efficiency.  Electronic records were simply not clinically useful.   Curry’s solution was  to hire a scribe to follow him around,  entering information and opening and closing programs.
  • · In January 2011 “In Saving Time and Practicing Better Medicine “ I commented at length:
“In The Successful Doctor: A Productivity Handbook for Practitioners (An Aspen Publication, 2000), Marshall O. Zaslove, MD, a West Coast physician who conducted productivity seminars for doctors, gave a few hints on how to save time while conducting a better, more productive practice.

1) Realize you’re the highest paid person in your practice, and you’re paid to see patients at the rate of $3 to $4 per minute.

2) You’re paid for your time and knowledge.

3) Spend your time with complex patients requiring your knowledge.

4) Delegate patients with simpler problems to physician assistants, nurse practitioners, nurses, and others.

5) Have patients in the reception room write down three questions that concern them the most. This will allows you to get to the heart of the problem quickly.

6) Look into acquiring software. This allows patients to generate their own history based on their chief complaint, age, and gender, before or during their visit, saving you 4 to 8 minutes per patient visit.

7) Ask your nurse or other members of your staff how you can do things better and faster. Often they’ll tell you practical things they’ve been dying to tell you for years.

8) Don’t allow unreasonable interruptions while you’re working.

9) Avoid administrative committees, unproductive conferences, and meetings that waste your time.

10) Buy a 20 gallon wastebasket for your office. Immediately (and gleefully) toss clinically irrelevant paper items into it.

11) Be careful how you use the phone. It takes up to 1/3 of some doctors’ time.

12) Consider charging for patient emails, and substituting these emails for phone calls.

13) Consider hiring a scribe to record relevant historical information and to enter data.

14) Consider installing an EMR but not until it is ready for prime time, saves time, boosts productivity, and is useful for communicating with others.

15) Consider applications of mobile devices to increase productivity – look for successful examples.

I could go on, but I will not. Instead, I will circle back to the opening quote an enter these observations from Peter Drucker: “Time is a unique resource..The supply of time is totally inelastic. No matter how high the demand, the supply will not go up…Yesterday’s time is gone forever and will never come back. Time is, therefore, in always in exceeding short supply. Time is totally irreplaceable."

Tweet: What’s important to patients is to spend time with doctors. That is what is important to doctors too. Listed here are ways to create more time

Saturday, October 27, 2012

Understanding Two Economic and Political Realities of Health Reform in the 2012 Election as Revealed by 37 Independent Telephone Polls
The end of understanding is not to prove and find reasons, but to know and believe.
Thomas Carlyle (1795-1881), Characteristics
October 27, 2012 – An article in the October 25 New England Journal of Medicine “Understanding Health Care in the 2012 Election”  reveals two economic and political realities of the 2012 election in   a project supported by the Robert Wood Johnson Foundation consisting of 37 independent telephone polls  conducted among both land-line and cell-phone respondents.
Reality #1 -  Health reform is important but it is dwarfed  by economic issues: 81% of respondents indicate health care is an important issue, but 51% choose the economy and jobs as as their top issue, compared to 20% for health reform.
The most important issues for voters by percentage of respondents are:
Rank #1 – Economy and jobs, 51%
Rank #2 – Health care and Medicare, 20%
Rank #3 – Federal budget deficit and taxes, 14%
Rank #4 – Abortion, 4%
Rank #5 – War in  Afghanistan, 2%, and Immigration, 2%
Reality #2 – Respondents favor current government programs of Medicare and Medicaid but this favoritism is unlikely to influence their vote.
Candidate’s position,  1. More likely to vote for this candidate,  2. Less likely to vote for this candidate, 3. no position.
·        Supports repealing all or parts of national health  care law passed in 2010, 14%, 41%, 45%.

·        Supports changing  Medicare so that people 64 years of age or older receive a payment or credit from the government each year for a fiexed amount that they can use to shop for their private health insurance plan or purchase Medicare coverage,  11%, 39%, 50%. 

·        Supports changing Medicaid, the health insurance program for low-income Amerians, from the current system to one in which the federal government gives states a fixed amount  of money and each state decides whom to cover and what services to pay for. 8%, 35%, 57%.

Source:  Robert J. Blendon, John M. Benson, and Amanda Brule, from Harvard School of Public Health and John F. Kennedy School of Government,  "Understanding Health Care in 2012 Election," New England Journal of Medicine,  October 25, 2012.
Tweet:  Most voters favor current government policies on Medicare and Medicaid but economic issues are more likely to influence for whom they vote.

Friday, October 26, 2012

A Bad Case of Obamnesia
A man’s memory of his past may become the art  of continually varying and misrepresenting his past, according to his interest of the present.
George Santayana (1863-1952),  Persons and Places
October 27, 2012-  A number of people have been bringing my attention to Kimberly Strassel’s article “A  Chronic Case of Obamnesia” in today’s Wall Street Journal.    I feel it is imcubent upon me to point out this Obamnesia extends to Obamacare – the fiction  that premiums will be cut by $2500 but instead have gone up $2500,  that the public will like it once it has been explained,  that seniors will embrace it once they wee what's in it, that it will extend access althouigh employers have thus far dropped health coverage for 20 million employees.
Here are Kimberly Strassel’s 11  examples of Obamesia.***
1)      "I happen to be a proponent of a single-payer universal health care program"—Illinois state Sen. Barack Obama, June 2003.

"I have not said that I was a single-payer supporter"—President Obama, August 2009.
2)      "Leadership means that the buck stops here. . . . I therefore intend to oppose the effort to increase America's debt limit"—Sen. Barack Obama, March 2006.
"It is not acceptable for us not to raise the debt ceiling and to allow the U.S. government to default"—President Obama, July 2011.
3)      "I favor legalizing same-sex marriages, and would fight efforts to prohibit such marriages"—Obama questionnaire response, 1996, while running for Illinois state Senate.
"I believe marriage is between a man and a woman. I am not in favor of gay marriage"—Sen. Obama, November 2008, while running for president.
"It is important for me to go ahead and affirm that I think same-sex couples should be able to get married"—President Obama, May 2012.
       4)      "We have an idea for the trigger. . . . Sequestration"—Obama Office of Management and Budget Director Jack Lew in 2011, as reported in Bob Woodward's "The Price of Politics."
"First of all, the sequester is not something that I've proposed. It is something that Congress has proposed"—President Obama, October 2012.
5)      "If I am the Democratic nominee, I will aggressively pursue an agreement with the Republican nominee to preserve a publicly financed general election"—Sen. Obama, 2007.
"We've made the decision not to participate in the public financing system for the general election"—Sen. Obama, June 2008.
6)      "I will never question the patriotism of others in this campaign"—Sen. Obama, June 2008.
"The way Bush has done it over the last eight years is . . . [he] added $4 trillion by his lonesome, so that we now have over $9 trillion of debt that we are going to have to pay back. . . . That's irresponsible. It's unpatriotic"—Sen. Obama, July 2008.
"I don't remember what the number was precisely. . . . We don't have to worry about it short term"—President Obama, September 2012, on the debt figure when he took office ($10 trillion) and whether to worry about today's $16 trillion figure.
7)      "[Sen. Hillary Clinton believes] that . . . if the government does not force taxpayers to buy health care, that we will penalize them in some fashion. I disagree with that"—Sen. Obama, Jan 2008, opposing the individual mandate for health insurance.
"I'm open to a system where every American bears responsibility for owning health insurance"—President Obama, June 2009, supporting the individual mandate.
8)      "Instead of celebrating your dynamic union and seeking to partner with you to meet common challenges, there have been times when America has shown arrogance and been dismissive, even derisive"—President Obama, April 2009, in France.
"We have at times been disengaged, and at times we sought to dictate our terms"—President Obama, April 2009, in Trinidad and Tobago.
"Nothing Governor Romney just said is true, starting with this notion of me apologizing"—Barack Obama, October 2012, on whether he went on a global apology tour.
9)      "The problem with a spending freeze is you're using a hatchet where you need a scalpel"—Sen. Obama, September 2008.
"Starting in 2011, we are prepared to freeze government spending for three years"—President Obama, January 2010.
10)  "So if somebody wants to build a coal-fired plant, they can, it's just that it will bankrupt them"—Sen. Obama, January 2008, on his plans to financially penalize coal plants.
"Now is the time to end this addiction, and to understand that drilling is a stop-gap measure, not a long-term solution"—Sen. Obama, August 2008.
"Here's what I've done since I've been president. We have increased oil production to the highest levels in 16 years. Natural gas production is the highest it's been in decades. We have seen increases in coal production and coal employment"—President Obama, October 2012.
11)  "If I don't have this done in three years, then there's going to be a one-term proposition"—President Obama, 2009.
"We've got a long way to go but . . . we've come too far to turn back now. . . . And that's why I'm running for a second term"—President Obama, October 2012.
These reversals may be a case of psychological “projection,”  where the President “projects”  faults of his own to his opponents. Whatever the reason – projection or political expediency – this may simply be a case of the pot calling the kettle black on the day after the President called Romney a “bullshitter” and the Vice-President said the GOP ticket was full of “mulkarkey.”
Tweet:  Obamanesia may be defined as forgetting what one has said in the past and reversing it to fit present political contingencies.  

Seven Causes of  High Health Costs: Left-Brain and Right-Brain Factors
Which of you, intending to build a tower, sitteth not down first, and counteth the costs, whether he have sufficent to finish it?
The Holy Bible: Luke
Currently, the United States spends more on health care services than any other country, exceeding $2.6 trillion, or about 18 percent of gross domestic product.  Most years, medical spending rises faster than inflation or the economy as a whole. Many factors - and nearly everyone- contribute to these increases.
 Julie Appleby,  “Seven Factors Driving Up Health Costs, “ Kaiser Health News, October 25, 2012
October 26, 2012  - In an excellent article,  Julie Appleby of Kaiser Health News identifies seven factors contributing to high health costs but no single villain.

1.      Pay our doctors, hospitals and other medical providers in ways that reward doing more, rather than being efficient.
2.      We're growing older, sicker and fatter.
3. We want new drugs, technologies, services and procedures.
4. We get tax breaks on buying health insurance -- and the cost to patients of seeking care is often low.
5. We don't have enough information to make decisions on which medical care is best for us.
6. Our hospitals and other providers are increasingly gaining market share and are better able to demand higher prices.
7. We have supply and demand problems, and legal issues that complicate efforts to slow spending.
The Malpractice, Defensive Medicine Factor, and Scope of Practice Factors
Of the last factor, she says: “Malpractice premiums and jury awards are part of what drives spending. A larger problem, although hard to quantify, is ‘defensive medicine’ -- when doctors prescribe unnecessary tests or treatment out of fear of facing a lawsuit, the report says. Fraudulent billing or unnecessary tests by medical providers seeking to ‘game the system’ are another concern.”  (This is no doubt true. Defensive medicine may cost the system in the neighborhood of $50 billion to $200 billion.  No one knows exactly how much. Fraud is estimated at $60 billion to $90 billion).
“Finally, the report notes that state laws sometimes limit the ability of nurse practitioners or other medical professionals, who are paid less than doctors, to fully perform work for which they are trained. The U.S. faces a shortage of primary care doctors, so more advanced practice nurses and others will be needed to help care for patients who gain insurance coverage under the federal health law. Conversely, the U.S. has a higher ratio of specialists than other countries, which can serve to drive up spending. Specialists have more advanced training than primary care doctors, and are paid far more( To complicate matters, U.S. patients often prefer  to be treated by a specialist).
On Target
Julie is on target with her assessment.   What she is describing are the natural consequences of human nature under the current system and are difficult to reverse.
·         Doctors act in their own best interest to enhance their income,  Who, in similar circumstances,  would not?
·         We get sicker and thicker as we grow older.  Aging has consequences.
·         As patients we want the very best for ourselves.  And for our families and other loved ones.
·         We take advantage of tax breaks. Breaks are there for a reason,  and special interests  make sure they stay there.
·         When  costs don’t effect them,  patients  use more care, Why not? Someone else is footing the bill.
·         Information may not available to judge what is the best thing to do. And in certain cases  It may never be – individual patients respond unpredicatably differently, and nature and disease are slow to yield their mysteries.
·         Doctors and hospitals flock together to protect their turf and may end with virtual monopolies,  Like it or not,  this is a consequences of collaboration,  which some may prefer to call collusion.
·         We have a doctor shortage, and our legal system with the ever-present threat of being sued  leads to high costs of defensive medicine. After all, one must protect oneself against the accusation that one did not cover all the possible bases.
Other Factors - Left Brain and Right Brain Thinking
But there are other factors as well.   These factors tend to be unspoken, intangible,  subjective, and very human.
These factors boil down to  left-brain thinking vs. right brain thinking.   
Left-brain thinking is scientific, sequential, logical, and rests on piles of data.  Number crunchers, federal bureaucrats and others with green eye shades using computers,  information technology techniques, and electronic health records can easily compile,  sift, analyze, dissect, parse,  and compose evidence-based data, protocols,  checklists, algorithms, rules, and regulations purported to elevate quality and otherwise rationalize, and if need be,  ration care and costs.  But, instead, left brain rules, with the time-consuming demand  for data entry, bureaucratic hassles,  and concentration on an all-inclusive  chart, distracts from patients,  eats up time, and drives up costs.
The right brain, the design mind,  and the thinking it produces differs.  Its thinking is based on pattern recognition,  intuitive leaps, clustering and chunking to make sense of data, recognition of body language and verbal cues,  and the knowledge-based on experience with thousands of patients,  recognizes that the human condition is full of vast immeasurable gray  zones and personal conumdrums..   The right brain can cut through the morass of data and reach sensible and quick decisions without wading through regulations and procedures designed to rationalize care.   It humanizes care. It is an art based on doctor-patient relationships, and sometimes goes by the name of bed-side manner and human sense.   It is a trait shared by many superb diagnosticians and commonsensical  doctors who can inexpensively and quickly  reduce medical and health problems to their essence.
Tweet:  Multiple American  cultural factors drive up costs of care, and these factors do not always yield to data-driven and protocol -driven care.