Monday, November 30, 2015

Physicians Rise in Unison Against “Meaningful Use” of Stage 2 and Stage 3EHR Mandates

Meaningful use (MU) is a health information technology context (HIT) defines U.S. government standards for Electronic Health Records (EHRs) for exchanging patient clinical data between physicians, between physicians and providers, and between physicians and patients.

Among physicians, there is a united movement to resist government interventions that create loss of physician autonomy, interference into physician-patient relations, mandated “Meaningful Use” of EHRs, and increased burdensome certification of doctors.

This movement took a tangible step forward in July 2014 when a large number of physician organizations and leaders held a physician summit, under the banner of United Physicians and Surgeons, in Keystone Colorado.

It took another giant step forward recently when 111 physicians organizations sent a letter to the AMA asking for a redesign of Stage 2 of the Meaningful Use EHR criteria with a delay of Stage 3 extension of those criteria.

The Three Stages

Stage 1, starting in 2010, was for CMS to promote EHR use. That stage succeeded, and some 80% of physicians now have EHRs in one form or another.

Stage 2, in 2012, was to increase EHR compliance to introduce clinical decision support and care –coordination and patient engagement, requirements .

Stage 3, from 2014 to 2016 was to make exchange more “meaningful” by punishing physicians financially for skipping Meaningful Use, and if by 2018, physicians did not comply by cutting reimbursement 1% a year up to a maximum of 5%.

Steps in Stage 2

Stage 2, for those of you not in the know, has six steps.

1) Use computer entry data order entry for medications, lab and radiology results.

2) Generate and transmit prescriptions electronically.

3) Use clinical support support to improve performance in high-priority health conditions.

4) Provide patients the ability to view online, download and transmit health information.

5) Incorporate clinical lab test results into certified EHR technologies.

6) Use secure electronic messaging to communicate with patients .

Clinical Burdens of Meaningful Use

All of these tasks require data entry for clinicians, hiring more personnel to enter data, time spent away from patients , and explaining to patients what Meaningful Use is all about.

In general, most physicians have accepted Stage 1 but not Stage 2 and 3. Physicians have rebelled against Meaningful Use in those two stages. Physicians agree that MU does not increase quality or improve care, requires unnecessary busywork, is overly expensive, and distracts from patient care.

In short, physicians across America in 111 physicians organizations have declared Meaningful Use of EHRs, in its Stages 2 and 3, to be a bloated $30 billion bureaucrat boondoggle, or boongoogle, if you're into word play, that converts physicians into electronic serfs for the government. The road to serfdom is electronic.

25 Reasons to Kill Stage 2 and Stage 3 Meaningful Use

In a biting commentary in the November 28 Health Care blog, Hayward Zwelinger, MD, gives 25 reasons that the time has come to kill Meaningful Use of EHRs.

1. The majority of physicians already use EHR and there is no reason to continue to incentivize them.

2. There is a ground swell of discontent among physicians arising from the poor design of many Certified EHRs and the current MU program further enshrines the use of these EHRs.

3. Many physicians believe that MU program interferes with the physician-patient relationship by forcing physicians to spend time acknowledging clinically meaningless Certified EHR prompts.

4. Hospital resources devoted to meeting MU requirements have hindered some hospital’s ability to update their IT infrastructure by drawing resources away from important IT problems.

5. MU mandates have onerously consumed EHR vendor and healthcare provider resources while decreasing resources which can be devoted to creating innovative healthcare solutions.

6. Physicians do not believe (nor is there data to demonstrate) that forcing patients to visit the physician’s MU mandated patient portal promotes the health of their patients.

7. Physician practices are overburdened with bureaucratic mandates (Rx appeals, insurance requests for records) and MU tasks consume staff and physician time, thus diverting them from patient care.

8. There are substantial financial penalties and psychological costs which physicians will incur if they are audited as a result of their participation in the MU program and these financial penalties are disproportionate to the financial incentives arising from the MU program.

9. Only 12% of physicians have completed MU stage 2 and fewer will likely participate in MU3.

10. The collective burden of all the workflow changes required by three stages of Meaningful Use regulations will make it hard for clinicians to spend adequate time on direct patient care (John Halamka, M.D.,

11. The public health reporting requirements required by MU will be hard to achieve in many locations due to the heterogeneity of local public health capabilities (John Halamka, M.D.)

12. There is no data which proves that achieving MU Stage 1 or Stage 2 improves the quality or reduces the cost of healthcare

13. A majority (68%) of physicians report MU measures do not help them improve patient care or safety. (Survey of Texas Physicians Meaningful Use. Texas Medical Association)

14. A decision to work towards a “delay” in MU Stage 3 program will enshrine the currently intrusive and wasteful MU1 and MU2 work protocols as part of the standard office visit.

15. While there is great promise which may derive from true HIT interoperability, there are many ways to achieve HIT interoperability independently of the MU

16. It is illogical to hold physicians responsible for implementing HIT mandates which are clearly beyond their ability to create, pay for and/or implement

17. Meaningful use has ” created … a monster, when really what we were shooting for was good patient care.” (Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems and Health Policy. The RAND Corporation, American Medical Association 2013)

18. Reducing the cumulative burden of rules and regulations may enhance physicians’ ability to focus on patient care. (Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems and Health Policy)

19. The current approach to automated quality reporting does not yet deliver on the promise of feasibility, validity and reliability of measures or the reduction in reporting burden placed on hospitals. (A Study Of The Impact Of Meaningful Use Clinical Quality Measures. Floyd Eisenberg,Caterina Lasome, Aneel Advani, Rute Martins, Patricia A. Craig, Sharon Sprenger. 2013)

20. The workflow changes to meet the MU eCQM reporting tool requirements have added to physician and nursing workload, providing no perceived benefit to patient care. (A Study Of The Impact Of Meaningful Use Clinical Quality Measures. Eisenberg et al)

21. EHRs are not designed to capture and enable re-use of information captured during the course of care for later eCQM reporting. (A Study Of The Impact Of Meaningful Use Clinical Quality Measures. Eisenberg et al)
22. Champions of EHR adoption within hospitals ….
have been significantly challenged by Meaningful Use Program eCQMs that are complex, inaccurate, outdated and that require incredible detail to be documented (often in duplicative ways) in a structured form in the EHR with no perceived additional value to patient care. (A Study Of The Impact Of Meaningful Use Clinical Quality Measures. Eisenberg et al)

23. Fifty two percent of Texas physicians report all or most of the (MU) measures are not meaningful to care. (Survey of Texas Physicians Meaningful Use. Texas Medical Association)

24. There is essentially no data which demonstrate that the vast majority of meaningful use measures (excluding clinical decision support and computerized provider order entry) improve the quality of patient care. (Ann Intern Med. 2014;160:48-54)

25. The existing MU program has had adeleterious effect on physician morale. (Robert Wachter, The Digital Doctor: Hope, Hype Harm at the Dawn of Medicine’s Computer Age)

A Closing Note

In closing, a personal note. I am suspicious of the use of the word "meaningful." "Meaningful", in my experience, is invariably condescending. Condescending deployment of "Meaningful Use" in Stages 2 and 3 has reached the limits of clinical usefulness, practical operability, and physician-patient intervention.

Sunday, November 29, 2015

Climate Change Confusion

The climate change debate confuses me. President Obama, about to depart for Paris for international summit of climate change containment, says climate change is a worst threat to mankind than terrorism.

Yet the earth is only 0.9 degrees Fahrenheit than 35 years ago, and globally, as scientists keep confirming, there has been no statistical increase in frequency or intensity of storms, floods, droughts, or natural disaster deaths, although the frequency and intensity of news reports would have you believe otherwise.

There may be alternatives to fossil fuels but with fracking and other high tech advances, these fuels are available in greater abundance at lower costs than alternatives . Solar and wind supply only 1.5% of energy needs, and for political reasons, nuclear energy is retreating.

I hope the President will share with the 200 nations at the summit the U.S. stellar performance in reducing green house gases. Our CO2 emissions reached a 27 year low in April 2015, and have declined by 9% since 2005, thanks in no small part to our exploding production of natural gas, a low carbon emitter which, because of fracking, has increased by 237% since 2006.

Good luck in Paris, Mr. President, in convincing other nations, particularly China (coal consumption up 2.6%) and India (coal consumption us 5.0%). For the present, at least, there is no economic alternative to fossil fuels in developing nations, especially those without electricity . Cheap natural gas is a powerful economic solution to reducing coal as a source of energy for producing electricity.

Still I suppose it is better to suffer economically now than to suffer environmental damage later.

The New York Times has provided us with short answers to hard questions about climate change.

• How much is the planet heating up? 1,7 degrees Fahrenheit since 1880.

• How much trouble are we in? Big trouble in 25 to 30 years, and more trouble later unless we do something now.

• Is there anything I can do? Fly less, drive less, waste less.

• What’s the most optimistic scenario? The earth becomes less sensitive to greenhouse gases, plants and animals adapt, nations reduce emissions.

• What’s the worst case scenario? Collapse of food production, coastal flooding, and unpredictable monsoons.

• Will a high tech breakthrough help? Yes, but it will cost an arm, a leg, and more cash than most nations, including the U.S., are willing to spend.

• How much will seas rise? Best bet is one foot per decade.

• Are predictions reliable? Evidence from past indicates as amount of CO2 rises in atmosphere, the earth warms, ice melts, and seas rise.

• Why do people question climate change? Because evidence is sketchy, and because of conservative ideology, money interests in fossil fuels, and short term denial rather than long term trends.

• Is crazy weather tied to climate change? In some cases, maybe, such as heavy rainstorms, coastal flooding, and drought in California and elsewhere.

• Will anybody benefit from global warming? Yes, maybe some nations will frozen hinterlands.

• Is there reason for hope? Yes, but the hour is late, and other nations, led by U.S. must get their act together.

If President Obama persuades other nations to follow his lead in controlling fossil fuels emissions, climate change may be slower with less damage than predicted, but it will also be more costly, more economically painful.


1. Matt Ridley and Benny Peiser, “ Your Complete Guide to the Climate Debate,” WSJ, November 28-29, 2015.

2. Justin Gillis, “Short Answers to Hard Questions about Climate Change,” NYT, November 28, 2015.

Saturday, November 28, 2015

Pfizer and Tax Inversions

In a $160 billion deal, Pfizer has agreed to merge with Allergen, an Irish drug company in a tax inversion, defined as a transaction used by a company whereby it becomes a subsidiary of a new parent company in another country for the purpose of falling under more beneficial tax laws.

In the case of Pfizer, the new merger would reduce its tax burden from 25% to 17%-18%,

This is a good deal for Pfizer and its stakeholders. President Obama says the transaction is “unpatriotic” because it deprives the U.S. government of revenues and transfers job abroad.

The U.S. at 35%, has the highest corporate tax rate in the developed world. Ireland, at 12.5% has one of the lowest rates. For this and other reasons, more than 47 companies have moved their headquarters abroad in the last decade with more to come. Medtronic and Walgreens are considering a similar move.

Ireland, with its English-speaking populace, and its experience in serving as headquarters with other drug companies is a logical place to go. Pfizer makes 60% of its profits overseas, and Ireland is a good place to park those profits until the U.S. lowers its corporate tax to Pfizer can compete with other global companies with foreign headquarters such as GlaxoSmithKlne, AstroZeneca, and Novartis.

Pfizer, to please its stakeholders, does not want to be double-taxed by the host country and the U.S., so it parks $74 billion abroad.

So why doesn’t the Obama administration lower its corporate tax to bring workers and cash back home? I suspect the reason is mainly ideological. The administration is no friend of corporate America. Nor is his possible successor. Hillary Clinton, who hopes to succeed Obama, says, “ We cannot delay in cracking down on inversions that erode our tax base.”

But does a high corporate tax rate erode the U.S. tax base? Experience indicates lowering tax rates, particularly capital gains, always increases government revenues. Lowering corporate rates would likely have the same effect.

Arthur Laffer, of Laffer Curve fame, has shown that when taxes reach a certain level, federal tax revenues fall. Pfizer’s move to merge indicates that a 35% corporate income tax has reached that level.

Pfizer CEO, Ian Read, has been travelling to Washington for two years, trying to convince Obama, his acolytes, and Congress and everybody who would listen that the corporate income tax rates was too high. Read claims because of U.S, tax code, Pfizer can invest only 65 cents on the dollar of overseas profits.

Pfizer’s solution?

Lower the corporate tax to be competitive with Pfizer’s drug rivals, or Pfizer will move to Ireland to merge with Allergen and to become the world’s largest drug company with revenues of $322 billion. Corporate America’s first obligation is to satisfy its stakeholders by promoting growth and profits, not to enrich the U.S. treasury or its overreaching bureaucracy.

The obvious solutions to preventing further tax inversions are to reduce the corporate tax, to simplify the tax code, and to stop punishing companies for investing in the U.S.

ObamaCare: Not an All-or-Nothing Proposition

Thou has seen nothing yet.

Cervantes (1547-1616)

Six years in, it is clear ObamaCare is not an all-or-nothing proposition.

As is, the health law is not accepted by the majority of Americans , Republicans, or Independents, or even Democrats. But they do not totally reject it either.

Certain aspects of the health law will remain - no exclusion by health plans for those with re-existing disease, coverage of young adults under their parents plans, coverage and subsidies for low-income Americans.

Other aspects of the health law are likely to go away or to be severely modified – individual, employer, and religious mandates, the raft of regulations that hamper small businesses and dampen innovative and entrepreneurship, and the compulsory use of electronic health records by physicians or Big Data as the final solution to almost everything, , to name a precious (and expensive) few.

Total repeal or total acceptance is not in the political cards.

Why the mixed picture? Well, in its present form, the Patient Protection and Affordable Care Act is neither protective nor affordable for many in the middle class.

Both political parties have dug in their heels and are unlikely to budge unless the American electorate says otherwise.

The sweeping GOP midterm victories in 2012 and 2014 assure this gridlock, as do two liberal rulings in the Supreme Court declaring the law as constitutional.

The health law has had its failures as outlined in a Human Events article in 2011 (“Too Ten Failures of ObamaCare after One Year.” The article listed these “failures”.

1. Explodes federal deficit

2. Kills jobs

3. Lose your doctor and health plan

4. State budget deficits to grow

5. Higher premiums

6. Crushes business

7. Fewer Americans to have access to care

8. Senior citizens to lose healthcare coverage

9. Overburdens small business

11. Tax hikes

Some of these things have come to pass, but not all and not all to the extent forecast.

The unemployment rate is 5.0%; 17.6 million uninsured are now covered thanks to the health exchanges and Medicaid expansion; overall government health care spending has ebbed; medical bankruptcies are fewer, and the government has initiated changes that it says promise to increase quality and integration, and save money, given time and good intentions.

Government oversight and failures have become more evident, and corrective market and political forces have kicked in.

I am optimistic, while the health reform law may not be all-or-nothing, something useful will turn up. Something is better than all or nothing.

Friday, November 27, 2015

Obama’s Passive Aggressiveness

I don’t care what color it is, as long as it’s black or white.


It’s black Friday, and I have a few black thoughts on my mind.

President Obama sees things in black or white terms. It’s his way or the highway. He's right and you’re wrong. If his policies fail, it’s your fault, not his. If you don’t see things his way, you’re the enemy.

In some circles, this attitude is known as passive-aggressive behavior , defined as the indirect expression of hostility, such as procrastination, stubbornness, sullen or deliberate and repeated failure to accomplish tasks for which you are responsible.

Obama repeatedly blames Republicans for his failures in domestic and foreign policy. His number one enemy is the GOP, not ISIS. He stubbornly refuses to call ISIS Muslim terrorists or extremists.

Obama procrastinated for seven years before making a negative and unpopular political decision on the Keystone XL pipeline.

He stubbornly refuses to talk to or compromise with the loyal opposition, who like him, have the best interests of the nation in mind, about such key issues as modifying ObamaCare’s dysfunctional mandates; or listening to his military advisors, who he continuously overrules; or to critics who tell him that the practical health of the economy on the middle class is more important than the distant threat of climate change on the planet; or to a bipartisan majority who think a pause in admitting refugees to the United States is an important measure in protecting us against imported terrorism.

Instead, the President is obsessed with raising minorities to a majority status, with achieving equal outcomes for all in spite of differences in skill and accomplishments, with punishing the successful with higher taxes and more regulations; with peace, concessions and appeasements to one’s foreign adversaries at any price, with avoidance of war and withdrawal from foreign affairs no matter what the consequences, with blaming and apologizing for the world’s past and present problems on American capitalism and European colonialism . For President Obama, these are black and white issues, with no shades of gray, no room for neutral points of view.

Mr. President. You’re responsible for America’s economic growth and for our success in foreign affairs. You’re our leader. We don’t expect perfection, and we expect debate and dialogue. Please don’t white wash your failures on the backs of your domestic enemies. We want you to succeed.

Thursday, November 26, 2015

Thanksgiving Is Brown

Thanksgiving is Brown

What other color could it be.

Christmas is Green.

New Year’s Day is White.

Easter is Yellow.

President’s Day is Purple.

Labor Day is Gray.

Independence Day, Veteran’s Day, Patriot's Day, and Memorial Day are Red, White, and Blue.

Columbus Day is Ocean Blue.

Martin Luther King Day is Black and Blue.

Valentine’s Day is Purple and Red.

Halloween is Orange.

That leaves Brown for Thanksgiving, an autumn Brown, a fallen leaf Brown, a dying grass Brown, a burnt squash Brown, a stuffing Brown, a left-overs Brown, a roasted and toasted Brown, a pumpkin Brown, a chestnut Brown, a coffee Brown, a chocolate Brown, a Brandy Brown, shades of Brown with a yellowish or reddish hue, and above all, a turkey Brown.

Wednesday, November 25, 2015

Four Health Law Questions with Applied Math Answers

Mathematics may be defined as the subject in which we never know what we are talking about, nor whether what we are saying is true.

Bertrand Russell (1872-1970), Recent Work on the Principles of Mathematics

I read today what an advocate of the Health Law and what an opponent had to say about the effect of the law (Affordable Care Act’s Next Phase: Leslie Dach Says It Has to be about Quality, not Quantity”; “Sen. John Thune Says Republican Alternatives Do A Better Job by Relying on Market Forces, “ WSJ, November 24), and I decided to apply a little math. After all, as a sage said, “In God we trust, all others use Data.”

Leslie Dach, a senior counselor for HHS observes that since the Law went into effect, 17.6 million more people now have coverage, a 45% drop in the uninsured rate.

Yes, says Senator Thune, that’s true but the cost has been $1.3 trillion, and 35 million are still uninsured, and, according to the Congressional Business Office, there will still be 27 million uninsured by 2015.

The first question. Has the cost of covering 17.6 million over the last 5 years been worth it? If you divide $1.3 trillion by 17.6 million, that amounts to $73,864 for each newly insured person.

The second question. Is this $73,864 worth the massive disruption it has created for the middle class, tax payers, patients, physicians, and hospitals. If one assumes America has a population of 320 million. $1.3 trillion divided by 320 million comes to $4062.40 per person. Whatever happened to that original ObamaCare promise that the health law would reduce premiums for a family by $2500? Instead the opposite has occurred, with premiums up $4865 for the typical family.

The third question. Has the spike in costs translated into increased quality and satisfaction ? The American people as a whole apparently think not since the average of national polls indicate 43.4% approve of the law while 50.0% oppose it.

The fourth question. Here we leave solid mathematical ground, does centralized national government or decentralized market forces do a better job at reforming health care? The question is moot since only the first has been tried.

Leslie Dach claims government is better because it incentivizes to pay for “quality not quantity” by doing away with fee-for-service medicine and by incentivizing care to be “integrated and organized.”

Senator Thune insists markets will do better through interstate competition, reduced regulations, doing away with mandates, grouping small businesses into high risk pools, expanding health savings accounts, having states regulate Medicaid according to the particular needs of each individual state.

Who knows the answers? The ultimate jury, the American people, are still out, at least until 2016 and undoubtedly thereafter. Until then, as the Mock Turtle in Alice in Wonderland, remarked, there will be “Reeling” and “Writhing” in the different branches of mathematics – Ambition, Distraction, Uglification, and Derision.” In the modern era of digitization, another branch, Big Datafication, may hold the answer.

Monday, November 23, 2015

ObamaCare As Deck of Cards

Patience, and shuffle the cards.

Cervantes (1547-1616), Don Quixote

Trust everybody, but cut the cards.

Mr. Dooley (1867-1936), Causal Observations

Picture ObamaCare as a deck of cards with two sets of dealers.

Dealers on the Right

Dealers on the Right are predicting ObamaCare will collapse like a house of cards before Congress has a chance to repeal it. These dealers point to UnitedHealthCare’s announcement it will cut back on its health exchange commitments in 2016 and probably withdraw altogether in 2017. United's CEO says United simply cannot afford to lose $425 million as it has so far on the exchanges. Its investors won’t stand for losses of this magnitude, unless of course the Obama administration steps in and bails out beleaguered insurers.

Dealers on the right also point to the collapse of 12 of 23 health exchange co-ops, with the remaining 11 teetering on the verge of bankruptcy. And finally, they observe that the Obama administration is forecasting that less than half of those originally expected to sign up for exchanges will do so. And those who do sign on are likely to be the chronically ill with high expenses that will drive costs and premiums even higher.

Next year more than half the states on the exchanges will experience double digit premium rises, and the accompanying deductibles and co-pays will be unaffordable.

Hence, an impending "death spiral", not enough of the young and healthy enrolling, higher premiums for the remaining folks, less of the latter signing on, and the House of ObamaCare Cards will come tumbling down. And all the King’s ( Obama’s) successors and all the King’s Horses ( future CMS, HHS, and other government agencies ) will be unable to put Humpty Dumpty (ObamaCare) together again (Rick Manning, “ObamaCare’s Predictable Collapse,” The Hill, November 22, and Editorial, “ ObamaCare Imploding Even Before Repeal, “ New York Post, November 23).

Paul Krugman, PhD, economist and New York Times contributor), A Dealer on the Left

The Right’s argument, asserts Paul Krugman, is a stacked, unshuffled deck. Somebody needs to cut the deck, and he's the man.

Everybody in liberal circles, Krugnab believes, knows that the federal government holds all the cards. Government sets the rules of the game. CMS is by far the single biggest payer of them all. Government has those all important trump cards, and two more - compassion and the conscience of humankind," in its hand. The end game, in his mind, universal coverage, is now in sight.

ObamaCare is, Krugman insists, a “huge success story,” with 17.6 million insured on Medicaid and the exchanges, with only 30 million uninsured to go. Krugman knows of what he speaks. Among his 10 books is The Conscience of a Liberal, and he has written 750 columns for Slate, the New York Times, and like-minded left-leaning publications. The critics may double down on ObamaCare, Krugman believes, but they will be in double trouble because the Health Law will double the number converted from the uninsured to insured.

ObamaCare, Krugman concedes, “is an imperfect system, but it’s workable - and it’s working ( Paul Krugman, “Health Reform Lives!” New York Times, November 23). And so it is and so it does, at least for the moment and for the rest of Obama's Presidecy, and for as long as the people believe the government can be trusted, a period which may be drawing to a close.

Our Next President

Who do we think should be our next President?
We hold these characteristics to be self-evident.

He or she should be a person who is strong,
Not someone weak who simply goes along.

He or she should be a person of action,
Someone who acts decisively with passion.

He or she should not be a mere talker.
Not someone who is a passive sleepwalker.

He or she should be a person who talks straight,
Someone who is confident in political debate.

He or she should be proud of the good old USA,
Someone who believes our values are AOK.

He or she should not for U.S. be apologetic,
Someone who for our values is sympathetic.

He or she should focus on being effectual,
Someone who is no feckless intellectual.

He or she should aim at home for budget austerity,
Someone who combines growth with prosperity.

He or she should focus abroad on respect,
Someone whose motives are not suspect.

He or she should be a leader from way up front,
Not someone who lurks behind, afraid to confront.

That is who we want to be our next President,
That is the ideal person we want us to represent.

Sunday, November 22, 2015

Are General Propositions Worth A Damn?

I daresay that the chief aim of many is to frame general propositions but no general proposition is worth a damn.

Oliver Wendell Holmes (1841-1935)

Eliminating uninsured is a worthy general proposition, but price is often frightful for taxpayers, economic growth, middle class, and individual liberties.

Ending discrimination on basis of age, gender, and religion are fine general propositions, except for those who cherish keeping traditional values of their own kind.

Paying doctors for “value” rather than “volume” is rational general proposition, but it requires regulations based on impersonal big data rather than on personal wants.

Universally connecting individuals through the social media is powerful general proposition, except it may breed narcissism and ignorance of collective society.

Tolerance for other cultures is admirable general proposition, but other cultures may be intolerant of you and demand you to submit to their ideology or be extinguished.

Equal outcome for all is an idealistic general proposition, except that it ignores human ambitions, skills, and drive to rise above and improve the lot of the common herd.

The secular belief that anything goes is understandable and pleasurable general proposition, but it may produce addictions, degrade society, and create anarchy.

Going to war against ISIS is widespread reactive general proposition, but to kill or be killed has hazards such as what does it take to do the job and what do you do when you win.

Innovation and entrepreneurship are proven general propositions for creating prosperity, but progressive taxes and onerous government regulations retard their implementation.

The French call for Liberte!, Egalite !, and Fraternite! are desirable general propositions, but are not free and must be coupled with a commitment to Securite! whatever the price.

Ten Other General Propositions about Health Reform

One, the poor and uninsured will always be with us, no matter how noble your intent or intent your desire to alter the situation.

Two, to satisfy most of the people most of the time and to stay in office, you have to keep changing the rules to satisfy more of the people more of the time.

Three, to cover most of the people most of the time, you have to use Other People’s Money – the Have’s, the Young, and the Healthy – and most of this money comes from the Middle Class, not from the Rich.

Four, to cover most of the people most of the time requires a healthy growing economy: that economy may require progressives embracing an economic system they do not believe in.

Five, to make health care affordable and to protect patients against insurers’ abuse is not about covering routine care: it is about health insurance that protects patients with chronic high cost diseases against catastrophe.

Six, to afford people with equal opportunities are not the same as guaranteeing equal outcomes; to try to equalize the two is to try to reverse the laws of human nature.

Seven, to achieve successful reform you must grasp the reality that many people prefer personal one-on-one care from a physician to team-care from an institution or from government.

Eight, to judge the “quality” of medicine, or the satisfaction of care delivered, by data outcomes alone is a fool’s errand.

Nine, to think of the computer as the only effective tool for improving health care is foolish and simplistic; the computer is not effective for communicating many people, for many of the people you want to reach are not computer-savvy nor do they care to be.

Ten, to achieve effective reform, you must recognize that individualism and humanism are not always compatible with collectivism.

Saturday, November 21, 2015

Public Approval, Disapproval of Health Care Law

Real Clear Politics Average, 42.6 50.0.

Against/Oppose +7.4

Gallup 44 52 Against/Oppose +8

PPP 42 40 For/Favor +2

Rasmussen Reports 43 52 Against/Oppose +9

FOX News 41 54 Against/Oppose +13

Quinnipiac 43 52 Against/Oppose + 9

National Physician of the Year Awards

Each year in March, Castle Connolly, Ltd, a medical company in New York City, presents the Castle Connolly National Physician of the Year Awards. As a member of the advisory board of Castle Connolly, who publishes books and articles on America’s Top Doctors, I am called upon annually to help select two Lifetime Achievement and three Clinical Excellence Awards. Clinical peers and hospitals nominate the candidates.

The candidates are invariably specialists from major academic centers who have pioneered innovations, written hundreds of papers, been national leaders in their specialties, received multiple awards, led or served on national specialty or editorial boards of their discipline.

This year’s candidates

Lifetime Achievement Nominees

• Joseph S. Torg, MD, Temple U. Hospital, Orthopedic Surgery, Sports Medicine

• Hricak Hedvig, MD, Memorial Sloan Kettering, Diagnostic Radiology

• W, Gerald Austen, MD, Massachusetts General Hospital, Chairman, Cardiac Surgery

• Arnold Cohen, MD, Einstein Healthcare Network, Obstetrics and Gynecology

• David Apple, MD, Shepherd Center , Atlanta, Orthopedic Surgery

• Suzanne Oparil, MD, University of Alabama, Cardiovascular Disease

• Richard J. O’Reilly, MD, Memorial Sloan Kettering, Medical Oncology

• Herbert Dardik, MD, Englewood Hospital and Medical Center, Vascular Surgery

• Randall Olsen, MD, University of Utah and John Moran Eye Center, Ophthalmology

• Valentin Foster, MD, Mount Sinai Hospital, Cardiovascular Disease

• James D. Crapo, MD, National Jewish Center, Pulmonary Disease

Clinical Excellence Nominees

• William J. Catalona, MD, Johns Hopkins, Urology

• Fred Telischi, MD, MD, University of Miami, Otolaryncology

• Alice Yu, MD, University of California, Pediatric Hematology-Oncology

• Jeffrey Speigel, MD, Lahey Hospital and Medical Center, Otolaryngology

• Ihor S. Sawczku, MD, Hackensack University Medical Center, Urology

• Victor Navorro, MD, Einstein Healthcare Network, Hepatology

• Ross Zafonte, MD, Spaulding Rehabilitation Center, Physical Medicine and Rehabilitation

• Phillip Stieg, MD, MY-Presbyterian/Weill Medical College, Neurosurgery

• Eva Feldman, MD, University of Michigan Health System, Neurology

• Debra Somers Copit, MD, Einstein Health Network, Diagnostic Radiology

• Mark R. Katlic, MD, Sinai Hospital, Geriatic Medicine

• Kenneth Anderson, MD, Dana Farber, Hematology

• Everett E. Vokes, MD, University of Chicago, Medical Oncology

• Robert Spetzler, MD, University of Pittsburgh, Neurosurgery

• Anthony Atala, MD, Wake Forest Institute, Urology/Regenerative Medicine

• Ricardo L. Carrau, MD, Ohio State University, Otolaryngology/Head and Neck Surgery

• Alberto Esquenazi, MD, Albert Einstein Medical Center, Physical Medicine and Rehabilitation

• Mani Menon, MD, Henry Ford Health System, Urology

A Footnote

Specialists in academic medical centers are the sinews of America’s worldwide reputation for excellence. This event, the Castle Connolly National Physician of the Year Awards, is medicine’s way of celebrating excellence. I consider it Medicine’s Academy Awards.

While we celebrate this event, it is worth noting these specialists and hospitals they represent are under financial stress because of cutbacks in federal funding, reimbursements for specialists, and ObamaCare regulations. With the reduction in federal grants and these other factors, these specialists and hospitals must make up the shortfalls.

How to do this? Victor J. Dzau, MD, president of the Institute of Medicine and an academic himself (NEJM, "Transforming Academic Health Centers for an Uncertain Future," September 12, 2013) has these comments and suggestions.

“ In academia, it is no longer be enough to serve your local and regional communities or to have a cluster of world class specialty centers. It is no longer enough to attract National Institute of Health and other grants. It is no longer enough to have a series of independent specialized fiefdoms connected by a common heating system, a commodious parking lot, and buildings held together by a prestigious academic name. It is no longer enough ‘Publish or perish.’ “

Now, faculty members must “transform or perish.”

Dzau et all cite the following factors as having brought about this new state of academic affairs:

• ObamaCare regulations

• Reductions in Medicare and Medicaid reimbursement

• Driving of health plan enrollees to lower cost providers and into narrow tiered networks of physicians and hospitals

• Ending of government funding for hospitals treating low income patients.

The result is that academic centers are falling 30 to 40 cent short for every federal dollar needed to support their research and educational missions.

How to respond?

Dzau recommends these survival strategies.

• Balance specialized clinic excellence with population health.

• Combine “centers of excellence” with research translating that excellence into training for doctors.

• Become high-performing regional health systems ”spanning the spectrum from community-based and primary care to highly specialized hospital and post-acute care, all linked by effective information systems.

• Increase research yields by translating results so they have an immediate impact on practices and services offering natural economies of scale and fostering innovation and entrepreneurship.

• Offer new ways to engage patients, through e-healthy, mobile devices, and increased personalization driven by advanced data analytics.

• Require centralized enterprise-wide planning and management to prepare for an uncertain future.

• Centralize coordination and tamp down with faculty individuality and autonomy will not be enough to get the job done.

ObamaCare : Where You Stand Depends on Where You Sit

Rufus Miles, Jr. (1910-1996), assistant secretary under presidents Dwight Eisenhower, John Kennedy, and Lyndon Johnson, and under 6 HEW secretaries articulated Miles Law which reads, “Where you stand depends on where you sit.
Nowhere is this law more relevant than with ObamaCare.

If you sit in the editorial offices of the conservative Washington Examiner, you will write articles with title like “ObamaCare Death Spiral a Gift to Republicans” November 19, or “The Health Law Is Crumbling Before Our Eyes,” November 20. You will cite the threatened withdrawal of UnitedHealth from health exchange markets; rising costs of premiums and out-of-pocket costs, the failure of the young and health to sign up for health exchanges, the cascading failure of ObamaCare co-ops, and for many, the impossible burden of researching, shopping, and switching health plans.

If you sit in the offices CMS or Health and Human Services or the New York Times, you will notice a different pattern, namely, that the Supreme Court has against endorsed ObamaCare ( Hooryay for ObamaCare, NYT, June 25, 2015) and that the number of uninsured are dropping in the East and Midwest but not in the conservative South and Southwest, and that given time, ObamaCare will grow in popularity and reach, given time and recognition that the health law is a good thing (“For Tens of Millions, ObamaCare Is Working, NYT, February 15).

If you sit in a physicians’ office, you may feel overworked, undercompensated, over-regulated, and overly-second guessed. You may even act by doing one of four things; retiring early, going to work for a hospital, becoming a locum tenens physician, or abandoning the traditional mode of private practice to go into direct patient contracting.

Many physicians are seeking to escape from the regulations and restrictions of ObamaCare by switching to Direct Patient Contracting (DPC). The American College of Physicians, the nation’ largest organization for internists has reservations about Direct Patient Contracting (“Warily, ACP Eyes New Practice Model,” The ACP fears patients with low incomes or minorities will be abandoned with alternative access to care or will be charged more than they can afford. The ACP says DPC has three components: 1) downsizing your current practice to send more personal time with patients; 2) charging a retainer or concierge fee; 3) not participating in patients’ insurance.

Practitioners who have switched to DPC say the ACP has it wrong and is oversimplifying. DPC, the practitioners say, has many variations- physicians who combine traditional practice with direct contracting with patients, direct cash transactions without retainers for patients who wish to retain their insurance, negotiated and lowered fees for patients with lower incomes, and bundled fees which include the visit, routine lab work, certain tests like EKGs, and minor surgical procedures such as skin lesion excisions. Furthermore , they maintain DPC is often less expensive than ObamaCare or insurance backed plans with their array of co-pays, premiums, and deductibles. For whatever reason, DPC is growing, and physicians and patients alike say DPC fills a need for what patients want - personal, more accessible care, available 24/7, with costs for services known upfront, without 3rd party intervention, with patient and doctor autonomy.

Thursday, November 19, 2015

The Business of Health Care

The chief business of the American people is business.

President Calvin Coolidge (1872-1933), Speech before American Society of Newspaper Editors, 1925

Whether the chief business of the American people is business is debatable. But economic growth and prosperity , more than national security, income gap between rich and poor, and health care, may be most important issue in 2016 presidential campaign.

These issues are intertwined, as reflected in these articles:

• “Health Care Law Forces Businesses to Consider Growth’s Costs,: NYT, 11/18

• “UnitedHealth Raises Doubts about Its Participation in Health Exchanges,” WSJ, 11/19

• “Why It Matters That New Businesses Are Creating Jobs More Slowly Than A Decade Ago,” WSJ, 11/19

. "Rising Rates Pose Challenge for Health Law," WSJ, 11/19

. "In Many of ObamaCare Markets, Renewal In Not an Option, 11/18

As we all know, health care has a moral component as well, namely, 1) reducing the number of the nation’s uninsured; 2) and making health care affordable.
ObamaCare may be succeeding on the first count while failing on the secondfor the middle class and businesses too.

In the face of such measures at the highest U.S. corporate income tax in the world, businesses will move headquarters , workers, and money abroad. Faced with an employer mandate that it must cover all workers it must insure al worker if it has more 50 employees or pay a $2000 fine for each additional, businesses will stop growing and fall short of employing 50 full-time workers. Confronted with heavy losses for insuring people in health exchanges, health insurers will drop out of the exchanges. Faced with the realities of higher premiums and outlandish out-of-pocket costs of ObamaCare plans, consumers will recognize a bad business deal and not renew.

Business is business and business must grow, and business must be profitable to compete and sustain itself, or it will drop out of the race or move to another place.

Top 20 Health Care Innovations for 2015

Here are 20 health care innovations from Brigham and Women’s Hospital and the Cleveland Clinic.

10 Brigham and Women’s Hospital Health Care Innovations

1. Use of “Big Data” to reduce costs for high-cost patients

Only five percent of patients account for about half of all U.S. health care spending. Analysis of large patient data sets can help providers better understand the health care needs of this small segment of patients, identify any gaps in their care, and adjust care accordingly.

2. Financial incentivizing of healthy behavior by employers

Companies are spending more on health care than five years ago. Employers are working to help employees live healthier. Nearly half of employers offer wellness programs. Financial incentives are also being used to encourage participation in these programs.

3. Innovations for managing outpatient behavioral health

30 percent of Americans have a mental health condition but less than a quarter of them seek help. Hospitals partnering with outpatient mental health agencies create a teamwork approach to patients in crisis. The link can seamlessly transition patients in and out of the appropriate facilities when an episode occurs. The use of telepsychiatry is also on the rise, providing counseling services to remote patients.

4. Expanded use of telehealth and digital health by clinicians

The expansion of coverage for telehealth services by Medicare coupled with expanded internet access is making telemedicine a viable option for delivering patient care. The addition of imaging and monitoring services offered through digital health services also adds value to telehealth visits.

5. Health care delivery goes retail to increase patient engagement

The move of retail giants like Walmart and CVS into health care delivery is grounded in the belief that improved health outcomes can be fostered in community settings. Patient engagement is key.

6. Increasing use of “wearables” in hospitals to continuously monitor biomarkers

The use of “wearables” allows for automated, continuous physiological monitoring. Sensors can be especially valuable in alerting clinicians of safety issues and sudden medical emergencies.

7. Increased prescription of health apps

Mobile apps allow patients to take more responsibility and interest in their health. Apps that can reduce costs through remote consultation will be especially valuable.
8. Care delivery innovation for end-of-life care

The goal of end-of-life care is to reduce suffering and respect the wishes of the dying. Telemedicine and digital health could enhance the care delivery of this sensitive patient population. Understanding patient priorities can also preserve quality of life.

9. Increased use of 3-D printing

Medical researchers are exploring numerous uses for 3-D printing. 3-D printing is being used to accurately map out the techniques of face transplantation pre-operatively and to follow progress of patients post-operatively. This provides better visualization for surgeons and better satisfaction with appearances for patients.

10. Better care delivery and engagement for the newly insured and millenials

The number of Americans born in the eighties and nineties (millenials) now surpass the baby boomers (those born in the fifties and sixties). Earnings of millenials are expected to surpass their parents’ by 2018.

10 Cleveland Clinic Health Care Innovations

#1 Mobile Stroke Treatment Unit

Each year in the United States, nearly 800,000 people suffer a stroke, or a brain attack. This occurs when an artery that supplies blood to part of the brain becomes blocked or ruptures and leads to bleeding in the brain. In ischemic strokes, a blood clot is the triggering event, while the remaining 10 percent of strokes are called hemorrhagic and a burst blood vessel or aneurysm is typically the cause.

#2 Dengue Vaccine

All it takes is one bite: Dengue is a debilitating virus that’s transmitted to humans by the bite of an Aedes aegypti mosquito that has previously bitten a person infected with the dengue virus.

#3 The New Art of Blood Collection and Diagnosis

With the advent of science, blood became a key diagnostic element. Withdrawn from the body, it was isolated and studied. Today, phlebotomy, the process of opening a vein and collecting blood for testing and diagnosis, is regularly used to measure cells, lipids, proteins, sugars, hormones, tumor markers and other blood components.

#4 PCSK9 Inhibitors for Cholesterol Reduction

Cholesterol, a soft, waxy substance present in cells throughout the body, serves many important functions. However, elevated levels of certain forms of cholesterol are some of the primary drivers in the development of coronary heart disease.

#5 Antibody Drug Conjugates

Scientists have learned more about cancer in the last two decades than had been learned in all the centuries preceding. And even though one million people in the United States develop cancer annually, tremendous advances have been made in cancer biology that have led to significant progress not only in cancer prevention and early detection but in cancer treatment as well.

#6 Immune Checkpoint Inhibitors

The immune system’s collection of organs, special cells, and molecules is on constant alert to protect us from dangerous infection and disease and keep us healthy. It responds to antigens, or foreign bodies, in a highly coordinated process that employs several types of cells to circulate around the body, scanning for cellular abnormalities and infections.

#7 Leadless Cardiac Pacemaker

The adult heart usually beats between 60 and 100 times a minute at rest, but if a person has bradycardia, a slower than normal heart rate, it indicates a problem with the heart’s electrical system.

#8 New Medications for Idiopathic Pulmonary Fibrosis

The lungs are remarkable organs made of spongy tissue that supply oxygen, the life-sustaining gas needed by the body. As the only internal organs that are exposed to the external environment, they are vulnerable to a variety of ailments. Some, like asthma, bronchitis, or even certain cancers, can be cured. However, when it comes to idiopathic pulmonary fibrosis, or IPF, eventual death is a certainty unless the lungs are replaced.

#9 Intraoperative Radiation Therapy for Breast Cancer

The American Cancer Society estimates this year about 233,000 new cases of invasive breast cancer will occur among women in the United States. In addition, 63,000 new cases of noninvasive breast cancer—the earliest form—will occur among women in 2014. It’s also projected that 40,000 women will die from breast cancer this year.

#10 Angiotensin-Receptor Neprilysin Inhibitor for Heart Failure

Heart failure is caused by a weakening of the heart’s ability to pump blood. Between 500,000 and 900,000 new cases of heart failure are diagnosed each year in the United States. This debilitating ailment is now the most common diagnosis in Medicare patients and accounts for 55,000 deaths annually.

Wednesday, November 18, 2015

Compassion Gone Awry

He who mocks runs risk of being mockedl


Suddenly, after the ISIS Paris attacks, compassion has gone out fashion. Governors of 31 states, 29 Republican, have said they will not accept Syrian refugees until the refugees can be properly vetted.

President has responded by mocking the Governors in particular and Republicans in general as enemies of compassion, afraid of allowing 3 year old Syrian orphans and their widowed mothers into the country, neglecting to mention that 70% of refugees are adult male and potential terrorists.

This conflict between Obama and his critics is understandable. Compassion has long been considered the hallmark of America (“Bring me your huddled masses”) and of the Democratic party, who believes most refugees will become dependable Democratic voters.

Besides, asserts the President, we cannot condemn Syrians on the basis on their Muslim religion “that is not the American way.”

Republicans counter after Paris, we are at war with radical Islam extremists. While it is true that not all Muslims are terrorists, most terrorists are Muslims, and we cannot reliably differentiate between the two.

Compassion is not necessarily compassionate, if:

• Terrorists are using the current mass influx of refugees from the Middle East and Africa as a screen to hide terrorists.

• The growing number of indigenous Muslim citizens do not assimilate into society and pledge allegiance to Allah and ISIS rather than to their host country, thereby posing a terrorist threat.

• The policies of the Obama administration prevent or restrain all-out attacks on oil facilities and command posts at the heart of the ISIS caliphate in the name of compassion and political expediency for fear if afflicting collateral damage.

There is no end in sight to this ideological conflict. War is war, and war is hell. Peace is better, but not if it invites surrender to an ideology that vows to dominate the world and rid it of infidels, no matter how innocent, if they do not submit to your faith.

Mocking your opponents for their lack of compassion when your anti-terrorism policies are not working is not likely to be productive.

Tuesday, November 17, 2015

ObamaCare: To Be Or Not To Be and What Should It Be?

To be, or not to be, that is the question.


ObamaCare: to be or not to be, that is the question.

It is question that haunts Democrats and taunts Republicans.

It is a question that will be a central issue in the 2016 presidential campaign.

It is a question with no easy answers which can never be completely answered.

It is a question I have addressed in over 3000 Medinnovation and Health Reform blogs and over a half-dozen books.

It is a question I shall pose in a future book by the same name.

It is a question the Supreme Court has partially answered on four occasions so far with more questions to come.

It is a question of compassion which is contradicted and complicated by rationing with more access for some and less access for others.

It is a question of having enough resources to cover a universal population with universal and inexhaustible demand.

It is a question of innovation and whether innovation can sooth or improve humankind's health enough to make a difference.

It is a question of government command-and-control versus individual- choice-and -freedom.

It is a question of liberal, conservative and independent ideologies.

It is a question of how to treat everyone’s health, which affects all, and end of life care, which shall come to all.

It is a question that involves one man’s legacy and every persons’ health.

It is a question of who is responsible for health - patients, physicians, politicians, our health system, our culture, or our economy.

It is a question of leadership, and whether a modern day Hamlet provides that leadership.

It is a question of if it is not be, what should it be?

Monday, November 16, 2015

Mr. President, Be Mindful of Your Vanity

Vanity of vanities, vanity of vani
ties, all is vanity.

Bible proverb

I listened to your explanations at your Turkey press conference about your multiple convoluted strategies for coping with ISIS after the Paris terrorist attack.

Mr. President, be mindful or your ideological vanity. I realize you are a proud person. You should be. Americans voted twice for you as their president, on the basis of your inspirational message about hope and change.

But be mindful that not everybody thinks as you do.

Not everybody agrees your multiple incremental strategies for dealing with ISIS ( you used the words “strategy” or “strategies” at least 30 times in your remarks) about “containing”, “degrading,” or “squeezing” ISIS. These multiple strategies do not constitute a single overall strategy. What you’re doing isn’t working, and your local political opponents and your international allies know it. You kept saying we will not change our strategy. What strategy and which strategy? Why not an understandable single strategy - liking declaring war against ISIS or simply destroying their oil fields - the source of their revenue?

Not everybody agrees that your statement about not changing your “strategies’ as a consequence of what happened in Paris makes much sense. When what you’re doing doesn’t work, you change.

You don’t remain “shiftless,” by saying what you’re doing needs more time., and you will not shift your strategies. You don’t say, ”If there’s a good idea out there, then we’re going to do it,” when you don’t listen to the ideas of your military advisors, whom you overrule every turn.

Not everyone agrees with your strategy of setting up hypothetical “strawmen,” who you say things they never really said, such as sending in 50,000 to 100,000 “boots-on the ground,” to win the war on ISIS, or deporting all Syrian immigrants back to Syria or going to war with Russia.

Other people have constructive ideas, and you don’t summarily dismiss them because you don’t agree with them. Don’t caste blame on others for their failure of your policies. Don’t be a scold, be bold and bring them into your fold. Listen to your fellow patriotic Americans, who think differently than you do.

Not everybody thinks all Muslims are terrorists, but to date, most terrorists have been Muslim. People are mystified why you are so reluctant to condemn terrorists by calling them ”Islam terrorists,” when, in fact, they are just that.

It is all right to sympathize with the majority of Muslims. It is not all right to speak up against Muslim leaders who fail to condemn terrorists, or to Muslim Americans who pledge allegiance to Allah rather than the United States of American.

Mr. President, “compassion” and “concern for the rights of others” has limits. Not everybody agrees we should take in an unlimited number of Syrian and other immigrants from countries where ISIS is active when those immigrants may contain many sympathetic to ISIS terrorists. Not everybody in the U.S. agrees that generous progressive welfare benefits work when violence and poverty are worse in those U.S. cities controlled by Democrats.

Be open-minded, Mr. President. You represent all the people, not just those who agree with your point of view.

Sunday, November 15, 2015

ObamaCare , the Health Care Balloon, and the Ineluctible Deductible

My wife went to her hairdresser recently, and she heard a group of women talking. All agreed they could no longer afford to see a doctor because of unaffordable deductibles. The women said they could no longer afford yearly physicals, much less care for routine or vexing health care problems.

What’s going on here?

Think of health care costs as a balloon. You’re a government or a business. You want to keep costs or the balloon volume constant. If you blow my costs into the balloon with more Medicare, Medicaid, and ObamaCare recipients, or obey government mandates to cover all full-time employees, you have to let air out for health care for the rest of us.

The balloon’s volume is growing with the government mandate that all Americans must pay a fine of $695 or 2% of income, if they do not have a health plan.

But how do you keep the balloon size the same without angering your voting constituencies if you’re a politician or your workers if you’re an employer?

You lower premiums, for that is something people pay monthly and identify as the true cost of care. And if you’re an employer, you throw in a sweetener called non-taxable Health Savings Accounts, which reward you for not seeking care and which can be transferred to next year or your retirement.

Deductibles are fast becoming inescapable or unavoidable. Robert Pear captures the essence of the problem high deductibles pose for consumers in this article “Many Say High Deductible Make Their Health Law Insurance All but Useless” (New York Times, November 15, 2015).

People asking: What good is health insurance if you can’t afford to see the doctor because of high deductibles?

Not to worry, President Obama says, “Most Americans will find an option that costs less than $75 a month.”

Sylvia Mathews Burwell, soothes recipients by saying,” Eight of 10 returning consumers will be able to buy a plan with premiums less than $100 a month.”

That’s fine on the front end, premiums, but what about the back end, deductibles?

In more than half the states plans offered for sale through have deductibles of $3,000 or more. In Miami, the medium deductible is $5,000; in Jackson, Mississippi, $5,500, In Chicago, $3,400; in Phoenix, $4,000; in Houston and Des Moines, $3,000.

For employers, the average annual deductible is $1,320 for individuals. For a family of four the deductible often runs $10,000 to $13,000.

The result of high deductibles is that most are paying for most of their medical expenses out-of-pocket. Most consider their policy only for emergencies and basic wellness appointments.

Much of what is happening to consumers fall into the category of health reform known as “Unintended Consequences of Well-Intended Health Reform.” Or, to paraphrase Abraham Lincoln, You can help and fool some of the people some of the time, but you can’t help or fool all of the people all of the time.

Saturday, November 14, 2015

ObamaCare As 5 Year Old

Imagine ObamaCare as a 5 year old. Its parents are two Democrat committees who wrote the 2700 genetic script for its upbringing, still mostly unread by its supporters.

By age 5, the script went, ObamaCare would be a lusty, healthy baby . Its parents and politic supporters would take pride in their creation. Americans would embrace it as a worthy sibling of Medicare and Medicaid.

ObamaCare would be the fair-haired child. It would cut costs, facilitate access to your favorite doctor and health plan, and improve the quality of care and health of the American people.

ObamaCare would be well on its way to adulthood, universal coverage for all. It would be fairest of all health systems.

But at 5, it came down with a mysterious ailment known in medical circles as “failure to thrive.” The majority of citizens disliked it. Its supporters and its siblings were having trouble finding doctors who would accept them as patients. Premiums and deductible and out-of-pocket costs were crushing middle class budgets. Costs were shifting from employers to workers. Nationals deficits and their step-child, higher taxes, were climbing to unprecedented heights, half of ObamaCare co-ops had left the market.

The health and longevity of Americans were lagging behind other nations, particularly among white middle-aged middle-class Americans: 38% of American adults were obese, the highest percentage in the developed world.

What to do? The baby’s parents and supporters say: give the baby more time to grow. Force-feed the baby with more taxes and more regulations. Control and modify its growth formula. Give the baby more time to grow into adulthood. Big Baby will get well. Things will be swell. Big Baby and Big Brother know best.

Above all, ignore the baby-haters , critics, who say the most hateful things (“ObamaCare at 5; Sick and Getting Worse, Orange County Register, November 14):

"As with every Big Government program, failure becomes the excuse to do more of the same, rather than to kill the contrivance and get government out of the equation. In the face of mounting deficits, escalating costs and failed bureaucracies, Big Government champions from Bismarck to Obama always insist failures happen because they just didn’t have enough time, enough money and enough control. The day nears when Obamacare’s failure will prompt demands for more time, more of your money and more control over your life.”

Trump’s Lack of Civility

In his remarks in Iowa, Donald Trump violated the elementary rules of civility. Trump accused his rival, Doctor Ben Carson, of irreversible pathological behavior for things that happened over 50 years ago when Carson was 13 or 14 years old. To make matters worse, Trump labeled Iowa voters who were thinking of voting for Carson as “stupid.”

Trump has a habit of calling anybody who disagrees with him as “stupid.” To me that pattern, which Trump calls “counter-punching” is not only pathological but stupid and lacks civility. \

In 1988, Applewood Books in Bedford, Massachusetts published Washington little 30 page volume on civility. It has a red cover, simulating leather, with its title on the cover in embossed gold print. The title is George Washington’s Rules of Civility & Decent Behavior in Company and Conversation. Trump ought to read it.

As I read it, I thought, By George! This is something Trump ought to read and heed.

To give you a flavor of what our first President said, here are ten of his rules.

#1 Every action ought to be done with some sign of respect to those who are present.

#2 Shake not the head, feet, or legs; roll not the eyes; lift not one eyebrow higher than the other; wry not the mouth, and bedew no man’s face with your spittle.

#3 Do not puff up the cheeks; loll not the tongue; rub the hands, thrust out the lips, or bite them, or keep the lips too open or close.

#4 Show not yourself glad at the misfortune of another, though he were your enemy.

#5 When you meet with one of greater quality than yourself, stop, and retire.

#6 Let your discourse with men of business be short and comprehensive.

#7 In writing or speaking, give every person his due title according to his degree & the custom of the place.

#8 Do not express joy before one sick and in pain, for that contrary passion will aggravate his misery.

#9 Use no reproachful language against anyone; neither curse nor revile.

# 10 In disputes not so desirous to overcome as not to give liberty to each one to deliver his opinion and submit to the judgment of the major part, especially if they are judges of the dispute.

Friday, November 13, 2015

Trump’s Lack of Civility

In his remarks yesterday on Ben Carson for pathological behavior and the stupidity of Iowa voters for thinking of voting for Carson, Donald Trump violated President George Washington’s rules of civility as set forth in a book Washington’s Rules of Civility & Decent Behavior in Company and Conversation.

Trump accused his rival, Doctor Ben Carson, of irreversible and perpetual pathological behavior for things that happened over 50 years ago when Carson was 13 or 14 years old, and he labeled Iowa voters who were thinking of voting for Carson as “stupid.” These biting comments may be the beginning of the end for Trump as a "Presidential" candidate.

Trump has a pathological habit of calling anybody who disagrees with him as “stupid.” To me that pattern, which Trump labels as “counter-punching” is stupid and lacks civility.

Trump criticizes any and all opponents as “stupid” .

His adversaries may be mistaken, but they are not stupid, i.e., lacking keenness of mind, slow, dull, foolish, senseless. They are accomplished people who are smart enough to be qualified presidential candidates.

Applewood Books in Bedford, Massachusetts published Washington’s little 30 page volume on civility in 1988. It has a red cover, simulating leather, with its title on the cover in embossed gold print.

As I read it, I thought, By George! This is something my readers ought to know. To give you a flavor of what our first President said, here are ten of his rules.

#1 Every action ought to be done with some sign of respect to those who are present.

#2 Shake not the head, feet, or legs; roll not the eyes; lift not one eyebrow higher than the other; wry not the mouth, and bedew no man’s face with your spittle.

#3 Do not puff up the cheeks; loll not the tongue; rub the hands, thrust out the lips, or bite them, or keep the lips too open or close.

#4 Show not yourself glad at the misfortune of another, though he were your enemy.

#5 When you meet with one of greater quality than yourself, stop, and retire.

#6 Let your discourse with men of business be short and comprehensive.

#7 In writing or speaking, give every person his due title according to his degree & the custom of the place.

#8 Do not express joy before one sick and in pain, for that contrary passion will aggravate his misery.

#9 Use no reproachful language against anyone; neither curse nor revile.

# 10 In disputes not so desirous to overcome as not to give liberty to each one to deliver his opinion and submit to the judgment of the major part, especially if they are judges of the dispute.

In his remarks on Carson, Trump violated these ten rules, and he may pay the price at the ballot box among voters who look forward to civilized discourse.

Populism - Down with Big Banks, Big Business, and Big Government

As a people, we Americans are mad as hell, and we’re not going to take it anymore – the expansion of big banks, big business, or big government. We’re going to lower taxes and regulations and let the people free to pursue their own interests.

In political circles, we call this populism. This emotion is responsible for the rise of non-politician candidates – Trump and Carson – and the fall of insider traditional candidates.

As John Steinbeck said in America and Americans in 1966,

“an obvious concentration of power or an official with a power causes in America first a restiveness, then suspicion, and finally – if the official remains in office too long – a downright general animosity…Such is the ruggedness of the path to election – the violence, the charges, the japes and hurtful tricks – that it takes a special kind of person to run for public office, a person with armored skin and a practical knowledge of gutter fighting.”

Fast forward to 2015 and the prelude to the 2016 elections, and you will find the same anger, a distrust for traditional politicians and loss of faith in capitalism.

The common triggering event for this set of emotions is the financial crisis. The crisis has lingered since 2008. It has created systemic anxiety because of the low 1.5% growth of the American economy , stagnant middle class wages, failures and low start-up rates of small businesses, and decline in entrepreneurship and innovation.\
A market research firm YouGov finds consumers think 65% of big businesses have dodged taxes, bought favors, or polluted; 55% think the rich get richer and the poor get poorer; only 14% think the next generation will be richer, safer, and healthier than the last, yet 49% still believe free enterprise is better at lifting people out of poverty than government.

At the fourth GOP debate, candidate were relentless in their attacks on Wall Street, big banks, the Federal Reserve, crony capitalism, the Pacific Trade pact, and ObamaCare.

Of the latter, Carly Florina commented the health law had prolonged the “cozy little game between regulators and health insurance companies,” another swipe at bigness.

The only federal entity that was spared was the military, which all but Ron Paul said must be rebuilt .

To paraphrase Winston Churchill, populism and capitalism combine to produce the worst and most unfair economic system – except for all the others that have been tried and failed.

Thursday, November 12, 2015

VA “Privatization”- The Power of a Word

Hillary Clinton’s recent remarks in New Hampshire on the evils of “privatization” of the VA health system show the power of a word.

To wit:

“ The VA problem is not as widespread as its been made out to be… and I will not let the Republicans use the problem as an excuse to privatize the VA…Privatization is a betrayal, plain and simple, and I’m not going to let it happen. ..the constant berating of the VA comes from the Republicans in pursuit of the ideological agenda they have.”

To which John McCain (R. Arizona) replied.

“Hillary Clinton’s downplaying the significance of the scandal in which veterans died while waiting care at the VA in Phoenix and across our nation while corrupt bureaucrats collected bonuses are disgraceful and shows lack of appreciation of the crisis veterans facing veterans’ health care today.”

Let’s put this in perspective.

Whose "ideology" are we talking about - Democrat ownership or Republican "free markets?

“Privatization” is defined at the transfer of ownership from a government to a privately owned entity. There is no suggestion of such a transfer.

Instead Republicans and Democrats have proposed giving health care vouchers to veterans so they can be treated by private physicians when needed or desired.

Vouchers to see a private physician hardly approach “privatization”, or “a betrayal, plain and simple,” of the VA.

Health care vouchers are not a betrayal or transfer of ownership to the private sector. Vouchers are a short-term way to cut waiting times, especially for veterans in rural areas remote from VA facilities, and to offer freedom of choice, while we wait for resolution of the VA’s problems – shortage of primary care physicians and specialists, long waiting times, inconsistencies of care, and a bloated bureaucracy.

Wednesday, November 11, 2015

Eight Concrete and Positive Alternatives for Physicians To Seize the Initiative on Health Reform

“The time has come,” the Walrus said, “to talk of many things,

Of shoes – and ships- and sealing wax –
Of cabbages and kings –
And why the sea is boiling hot
And whether pigs have wings.

Lewis Carroll (1832-1898), Alice in Wonderland

With health reform, physicians have been on the defensive too long. We have complained about our limited role in the scheme of things. We have pointed out ObamaCare’s deficiencies. We have said we are demoralized. We have groused we are not part of the health reform conversation.

Those days may be over. The time has come to seize the moment, to unite, and to put forth concrete, constructive, and positive reform alternatives. Because of the widespread unpopularity of ObamaCare and its persistent unworkability, Americans, doctors and patients alike, are looking for alternatives, any alternatives.

Here are 8 alternatives to improve health care delivery.

One, have existing major physician organizations coalesce around positive proposals to improve care and to broadcast these proposals to the American public and policymakers. Under the leadership of Richard Armstrong, MD, the recently formed United Physicians and Surgeons Association has already taken a step in this direction by hosting a summit meeting of health care leaders and organizations in July 2015 (see

At that meeting, physician leaders from SERMO, Doctors4patientcare, the Free Market Medical Association, the Physicians Foundation, and various medical associations presented ideas on how to make the system better. Their talks are available on videos and are available for distribution. In addition, an interview with Dr. Armstrong may be found on my blog Medinnovation and Health Reform (October 24, 2015). Dr. Armstrong explains physicians’ point of view on health reform. Similar interviews may follow,

Two, make electronic health records(EHRs) more useful, affordable, and interoperable among patients and physicians. Over 80% of practicing physicians have these records in their offices. Time is overdue to make EHRs more functional for both patients and physicians. One candidate for president, Dr. Ben Carson, has suggested every patient in the U.S. have EHR from birth, and the EHR be owned by the patient and be portable and accessible when the patient visits doctors. It is imperative that these records be under the patient’s individual control and be electronically secure.

Three, encourage physicians to organize “focused factories” This is Harvard business school’s Regina Herzlinger’s term for physician centers that address and treat specific diseases or perform repetitive procedures on ambulatory patients. Because these centers, which are frequently free-standing, do volume of work on common conditions or procedures, they are efficient and of high quality.

Four, let physicians develop and distribute mobile apps to their patients. We live in an information technology age, and more and more Americans have mobile phones. Why not have apps that help with issues like recovering from surgery, managing cancer-related pain, blood-thinners in patients with atrial fibrillation, anything that enhances physician-patient communication and improves outcomes and reduces emergency room visits or hospitalization.

Five, foster the use of telecommunications in those situations in which access to care in difficult or inconvenient. There are several variations off this theme. Skype connections with patients in rural areas; bedside monitoring of vital signs and visual images of bedridden patients with patients having the ability to initiate a physician encounter if patients perceive they are having a complication; and, of course, monitoring of wearable or implanted devices.

Six, give physicians the ability to prescribe social services – home care, nurse or physician visits, health care transportation, social worker access, home heating or cooling services, and even job placement – by having trained college, technology-savvy, volunteers set up “ help desks” in clinics and doctors’ offices so that these volunteers can direct patients to needy patients. This concept, pioneered by Health Leads, a Boston-based nonprofit, now exists in a half-dozen or more U.S, cities and has been backed by several million dollar grants from the Physicians Foundation.

Seven, encourage collaborative relationships between physicians and hospitals. These relationships do not require physician employment, but instead are based on arms-length relationships. For example, the Surgical Center of Oklahoma , which performs multiple ambulatory surgeries for requiring a one-day visit, is an independent entity that has a contractual relationship with a nearby community hospital to which it sends more complicated cases requiring overnight or more extended care.

Eight, be realistic. Individual or small practices may not hare the managerial or bureaucratic wherewithal to handle all of these problems. Some physicians may choose direct-cash arrangements without third party payment, but most will not be able to do so because of the local competitive. regulatory , or corporate environment. As I suggested in my 1988 book, And Who Shall Care the Sick? The Corporate Transformation of Medicine in Minnesota, “To survive and thrive over the long haul, physicians may have to fight fire with fire and form doctor corporations. These corporations will be limited partnerships, in which independent practitioners, as a group, will have a central management team that will handle billing and employment of personnel, negotiate legal and financial contrasts, response to requests from other organizations for service, and provide benefits for each limited partner.”

The long haul, described 27 years ago, has arrived.

Monday, November 9, 2015

We Have Met the Enemy, and He is Empathy

We have met the enemy, and his is us.

Walt Kelly (1913-1973), Saying on Pogo Poster

The first patient I saw as a medical student was a middle-aged man asking for demerol to relieve retro-orbital pain. I was empathetic. I asked the attending what dose we should prescribe. The internist supervising my work said, “ Did it occur to you that his man is an addict?”

Richard Friedman, MD, a Cornell professor of psychiatry , says too much empathy on the part of physicians may be killing more white Americans between 49 and 54 from overdose from opioid painkillers than in other advanced nations (“Doctors Enabling Americans, New York Times, November 9, 2015).

Friendman explained the problem:

“ Starting in the 1990s, there has been a vast expansion in the long-term-use to treat nonmalignant medical conditions, like low back pain and various musculoskeletal disorders…through aggressive marketing by drug companie that made new and powerful opioids , like OxyContin…the pitch to doctor seemed sensible and seductive. Be proactive with pain and treat it aggressively. After all, doctors have frequently been accused of being insensitive to pain and undertreating it. Here was the corrective, and who in their right mind would argue that physicians shouldn’t try to relieve pain whenever possible.”

In short, show empathy towards those in pain. But doctors underestimated the addictive power of OxyContin and similar drugs. Opioid use is now reported in 39% of ER visits, costs of opioids skyrocketed 8 times those of non-users, and overdoses from opioids and heroin and deaths rose to staggering levels.

Friedman suggests medical students, residents, primary care doctors and internists, should be intensively educated , trained and warned about opioid risks.

Friedman ends his article with this sad comment “It is physicians who in large part, unleashed the current opiod epidemic with their promiscuous use of these drugs; we have a large responsibility to end it.”

A little too empathy when it comes to relieving pain can be a dangerous thing.

Saturday, November 7, 2015

ObamaCare: End of the Ninth Inning

Baseball breaks your heart. It is designed to break your heart. The game begins in the spring, when everything else, begins anew, and it blossoms in the summer, and then as soon as the chill rains come, it stops, and leaves you to the face the fall alone.

A.Bartlett Giamatti (1938-1989), Commissioner of Baseball, The Green Fields of the Mind>

ObamaCare may be in the last inning of a health care game that has now lasted for five years. The game began in March 2010 and may end in December 2016. It is likely to go extra innings. It pits the middle class, many of whom feel they cannot afford to stay in the game, against the lower income class, who cannot stay in the game without subsidies.

The middle class pitcher is part of a team that is angry because it feels shortchanged. Most of his teammates are journeymen blue collar players who hail from the south and midwest, and they feel the media and national politicians have neglected them. The media has trumpeted the success of their opponents. It is almost like the Kansas City Royals against the New York Mets, the darlings of the Eastern elite.

Here is how the ninth inning has gone so far, for the pitcher, with his center right fastballs against center left batters.
Batter Number One

Strike one - “If you like your doctor, you can keep your doctor.”

Strike two – ObamaCare “will save you $2500 per family.”
Strike three - ObamaCare will add “not one dime” to the budget deficit.
Batter Number Two
Strike one - launch is botched.

Strike two - Jonathon Gruber, an MIT professor and a chief architect of health law, admits the game was rigged from the beginning.

Strike three – 100% of Congressional GOP did not vote for health law, polls indicate 50% to 60% of Americans oppose ObamaCare, 25% have been hurt by its provisions, and 70% to 80% say they don’t understand it and are confused by it.

Batter Number Three, still at the plate.

Strike one - Individual mandates, employer mandates, and contraceptive mandates run into political flak.

Strike two - 20 of 50 states, most with budgets that must be balanced by law. oppose Medicaid expansion because it blows holes in their budget and takes away from other priorities, such as roads and bridges and education.

Batter Number Three - Final pitch has yet to be thrown, but premiums and deductibles and budget deficit is growing, and dissatisfaction is mounting among 90% of citizens whose income and taxes are being re-distributed to support the lower 10 %.

It is possible the batter will hit a foul ball, the pitcher will walk four batters after striking out the first two batters and the game will go extra innings. Another possibility is he will strike out the third batter, and ObamaCare will be out of there.

Friday, November 6, 2015

Reece’s Thesis – Personal, Patient-Generated, Online Health Analysis Has Pluses and Questions

Before you even see a doctor, existing information technology (IT) makes it possible for you to record your medical history, including your health habits; your personal vital signs (BP and pulse), and physical measurements (height, weight, waist size); analyze your breath and your ECG, and arrive at an accurate assessment of your wellness status and disease diagnosis.

Theoretically, such an online analysis would help you prolong your life , warn you of the consequences of your bad health habits, stop or maybe even prevent the major killers of Americans – health disease, diabetes, some cancers, and respiratory ailments.

Then, should you choose to do so, you can collaborate with your doctor to chart a proper course of action.
So much for the positives, now for the questions.

Although such a personal data analysis is possible, is it desirable?

Will patients be able handle the information and make wise decisions ?

Will patients regard the results an invasion of their privacy , a threat to their jobs, and a horsecollar on their personal freedom?

Will IT result in a realistic action plan, change destructive health habits, and prevent premature deaths?

Will physicians regard such IT analysis as an encroachment upon their turf?

Will IT spawn expensive, fruitless, further testing, and needless worry? When it comes to health care, a little knowledge and a lot of information can be a dangerous thing.

Nevertheless, when used properly in the hands of patients, and with physician guidance, online heath IT are a useful tool for disease prevention and more precise diagnosis, ideally with physician collaboration

Is ObamaCare An Albatross?

A metaphor for a dead weight or burden that one must carry, especially when the burden is not a literal one but a stigma of some kind that one cannot easily discard or throw off. The name comes from a story about a sailor who killed an albatross that was following his ship, an act thought to bring bad luck upon the ship. His fellow sailors made him wear the dead albatross around his neck as penance to ward off the bad luck.

Definition of Albatross

The Wall Street Journal has labeled ObamaCare an albatross “The ObamaCare Albatross", November 5). The Journal did so largely on the basis of the Kentucky governor election, in which a Republican won the governor’s race for the first time in 40 years.
The winner, Matt Bevin, won by running against ObamaCare. Bevin said that Kentucky could no longer afford its Medicare expansion, the collapse of its ObamaCare exchange has left 51,000 residents without coverage, 40% of Kentucky hospitals had cut services because of soaring Medicaid costs, and ObamaCare exchange premiums will rise by 10% and more in 2016..

But is ObamaCare really an albatross? True, it has not delivered on its promising of cutting costs and expanding choice. But it has cut 17 million from the uninsured roles, subsidized nearly 9 million on the health exchanges, added 500,000 on Medicaid and the exchanges, and dropped the number of uninsured from 20.4% to 9.8% . That, by definition, is progress, note the Progressives.

Perhaps so, but Kentuckians and American people have yet to get the message.

In today’s Real Clear Politics, the average of national polls indicate Americans still oppose ObamaCare by 49.5% to 42.3%. Two years post rollout and five years post passage, Americans oppose the health law as strongly as even.

And it is generally acknowledged that ObamaCare is a potent factor in electing Republicans in conservative-leaning states. Since Obama took office. Democrats have lost 18 Senate seats, 69 House seats, 11 governor seats, 913 state legislative sears, and 30 state legislatures.

These losses make ObamaCare hard to implement and may foretell of major changes, even repeal, or replacement of the health law.

It’s hard to soar with the Democratic eagles when you’re dealing with Republican turkeys, who say they know an albatross when they see one.

Wednesday, November 4, 2015

Is ObamaCare Imploding or Exploding?

Obamanites insist the health law is set to explode to rival Medicare and Medicaid as popular federal programs to protect the public by making health care affordable.
This has not yet happened in the 7 years since the health law passed. But, argue advocates. big time, complex, compassionate social initiatives affecting millions take time, or so the government elites say. Maybe ObamaCare just has a long fuse, about to ignite.

Conservatives maintain 7 years is long enough to judge the merits of any social program, and ObamaCare will implode once its consequences - higher premiums, massive deductibles, rising out of pocket expenses, and limited access and choice of doctors, hospitals, and health plans become evident.

The conservative worldview does not sit well with progressives “who believe they are smarter than the masses, who think people are not capable of self-government, who fancy themselves as intelligent social designers, or who simply have a hard time imagining non-command-and-control solutions to problems”.

So reasons Matt Ridley, an evolutionary biologist, in his book The Evolution of Everything: How New Ideas Emerge (Harper, 2015), like the Internet and the mobile phone revolution.

Ridley says, “ Far more than we like to admit, the world is to a remarkable extent a self-organizing, self-changing place…Skeins of geese form Vs in the sky without meaning to, termites build cathedrals without architects, bees make hexagonal honeycombs without instruction, brains take shape without brain-makers, learning can happen without teaching, political events are shaped by history rather than vice-versa.”

Maybe people and their doctors can self-organize a health system a system that suits both. Maybe overwrought central planning is unnecessary. Maybe we can create a better balance between top-down design and bottom-up freedom. Maybe we ought to decentralize than centralize care. Maybe in a self-organizing system we can achieve a more patient-friendly, convenient, and less costly system.

Maybe all those ObamaCare skeptics writing about the “ObamaCare implosion” are right with articles entitled “ObamaCare Rapidly Imploding” ; “The Slow Motion Implosion of ObamaCare;” The ObamaCare Implosion is Worst Than Thought”; “The ObamaCare Co-Op Implosion”; “Watch ObamaCare Implode”; “ObamaCare Implosion: It’s Not Just the Website.”

Maybe ObamaCare will explode, as others are saying “ObamaCare’s Medical Enrollment Explosion”; “Overhead Costs Explosion under ObamaCare”; “ US Welfare Costs Explode under ObamaCare”, “Insurers Predict 100% to 400% ObamaCare Rate Explosion.” “To explode is to burst forth with force, noise, and emotion. ‘

It seems to me, ObamaCare is both implosive and explosive, with the explosive preceding the implosive.

Who’s at Fault for Health Care’s Problems?

Improving health requires changing the society itself, not just individual society.

Jeff Goldsmith, “Who Is to Blame for Health Care’s Problems,” The Health Care Blog, October 28, 2015

Who’s to blame for health care’s problems – costs 3 times what they were in 1965, when Medicare made its debut, longevity lagging behind other developed nations, and now, a sudden spike in premature deaths in whites aged 45-54 ?

Unhealthy patient behavior? High physician incomes? Wasteful government spending?

The answer may be: all of the above. The answer may be twofold: 1 ) the nature of American society, with its penchant for individualism and reliance on prescription drugs, and 2) slow economic growth, creating a sense of despair among the middle-aged, who no longer feel they can achieve the American dream of living better than their parents.

Between 1999 and 2013, the Proceedings of the National Academy of Sciences reports death rates per 1000,000 people, among whites aged 45-54 in round numbers were: 420 for U.S., 325 for France, 300 for Germany, 375 for U.K., 250 for Canada, 225 for Australia, and 210 for Sweden. Yet the U.S. spends at least twice what these other nations spend.

Jeff Goldsmith, President of Health Futures, Inc, says the usual narratives explaining the culprits for this spending spree are:

• Among conservatives, The Patient. Patients they argue smoke too much, eat too much, consume too many sugary drinks, exercise too little, and rely too much on prescription and non-prescription drugs. Bad health behaviors that lead to health disease, diabetes, and lung ailments.

• Among liberals, The Physician. Physicians, they contend, have target incomes to reach, and the use the fee-for-service system to do too many tests and perform too many procedures to reach their target.
The progressive solution is to stress prevention and wellness and to replace FFS “volume” with data-based “value” outcomes, and to pay physicians accordingly. Congress has embedded this concept into value-based physician payment incentives in 2015 Sustainable Growth Rate fix.

The truth is that neither the conservative or liberal fix is wholly right or wrong. Smoking, obesity, and reliance on drugs rather than good health habits do have a negative health effect. And, in theory, prevention and wellness, decreasing and rationalizing physician ordering, and regulating cigarette, alcohol, and drug advertising improves health among society.

The reality is health spending and health results depend on both patient and physicians, but larger factors are at play. Population health is 60% determined by social-societal factors, with genetics and inheritance 5%, health behaviors 25%, and medical care 15%, playing secondary roles.

In the U.S, according to the Centers of Disease Control and Prevention, a combination of factors are at play behind the surge of deaths among the middle-aged.

These factors include: a stagnant economy which has grown an average of only 1.7% of GDP since 2000, causing a sense of despair and depression among many and an overreliance on drugs as substitute for good health habits. Since 2000, mortality rates among the 45 to 54 crowd are up 7% to 30%, suicide up 15% to 25%, and chronic liver disease 15% to 22%. This is the case particularly among whites, who have much higher rates of taking prescription pain-killers, who die in far grater numbers from overdoses and suicides.

Goldsmith maintains there is no simple solution to our health problems. Neither seeking to change patient health behavior or physician ordering patterns or pay will solve the problem. Investing more heavily in public health might and reducing the number of uninsured might, and so might taking steps to speed economic growth to lift people out of economic despair.