Sunday, January 31, 2016

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

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


Saturday, January 30, 2016

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

On Slow Economic Growth
The U.S. economy grew by only 0.7% of GDP in the last quarter,  and it has only grown by 2.0% in the last 7 years, the slowest economy recovery from a recession since World War II.   To be fair,  under Obama, recovery has been sluggish, fitful, faltering, and historically weak but  it’s a recovery nevertheless, perhaps justified on moral grounds.  Slow growth has led to stagnant incomes, to economic anxiety, to political unrest to reduced health care access.
Is this slow growth due to Obama’s economic policies,  GOP obstructionism,  or factors beyond his control, such as the slow growth of the world’s economy?   Does the U.S, highest corporate income tax in the world contribute?   What about  those  inversions ;that are driving  major U.S. corporations  abroad to avoid high U.S. taxes? What about  the $500 billion in 20 new  taxes attributed to ObamaCare or those 8200 pages of new regulations on business?
Would lowering taxes and lightening regulations “lift all boats”? Would these moves  alleviate the economic  burdens on the middle class whose incomes have shriveled by 10%? Would a smaller government placate the rise gorge of populist anger? Or will it take a socialistic government to dampen the revolt among the young and idealistic?
Or would these moves lead to increased income inequality between the rich and poor and middle class?
 Is there in inverse relationship between government growth and economic growth?  Is there something to the saying that if you tax something more you will get less of it? Of is the Laffer Curve simply laughable? Is the economy trickle-down or bubble -up?
Economic growth,  lack of it,  or unfairness of it  are the key issues in the 2016 elections.  
On the Democratic side,  the candidates are saying economic growth is good but not if it produces unfairness.   Taxes on the rich and  on the middle class are necessary to right the social ship,  even,  in the case of Bernie Sanders,  it comes at the cost of $18 trillion to provide Medicare- for-all and free –college- tuition- for-all  and other assorted government goodies.
That’s too much ballast for the U.S. Ship of State,  say GOP candidates.  A rising tide lifts all boats.   Economic growth, not fairness,  is the number one political issue.  Lift   that boat,   tote that barge,  lighten those taxes and regulations,   and growth will soon lift  to 4% rather than an anemic  2%.  And all interests, for the rich, the middle class, and poor will be served
Says George Will, it’s a matter of simple arithmetic (The Simple Arithmetic That Could Jump-Start America’s Economic Growth.” Washington Post, January 29, 2015).    And observed Lewis Carroll in Alice in Wonderland 150 years before Will,  “Reeling and Writhing, of course, to begin with, and the different branches of Arithmetic – Ambition, Distraction, Uglification, and Derision.”
Slow growth and how to speed it up is  an ugly business,  with plenty of mixed motives to go around.   Economic growth is a messy business. But, given the resilience of a  freedom-loving entrepreneurial nation,  we’ll meddle and muddle through.



Friday, January 29, 2016

 DIY (Do-It-Yourself) Health Care Technologies

In recent years, do-it-yourself (DIY) health care technology has become a topic of speculation…as smart devices and wearable technology promise homes, workplaces,  and mobile phones into more accessible sites for home monitoring and intervention
Jeremy Greene, MD, PhD, General Internal Medicine, Johns Hopkins University School of Medicine,  “Do-It-Yourself Medical Devices and Empowerment in American Health Care,” NEJM, January 28, 2015
You can never tell what people will do when left to their own devices,  to do what they want to do without external control.  I am talking about DYI (Do-It-Yourself)medical devices, which allow you to do for yourself what doctors would otherwise do for you.
In his January 28  NEJM article,  Doctor Greene concludes, “It’s important to remember that DYI medical technologies are neither wholly new or wholly liberating. And in offering another means of circumventing physicians , they may well expose patients to new costs and new risks.”
Dr. Green chronicles self-designed  technological  monitoring devices, which have existed  136 years  (Blake, CG, “The Telephone and Microphone ins Auscultation,  Boston Medical Journal, 1880).
Lately DYI has experienced a renaissance as health reform see it as a way of reducing costs by letting consumers to their thing without doctors.   PriceWaterHouseCoopers, the giant accounting and consulting firm  ranks it number 1 among health care developments in 2015. Qualcomm, another giant health care firm is offering  $10 million competition prize to “stimulate innovation and integration of precision diagnostic technologies , helping consumers make their own reliable health diagnoses anywhere, anytime.
I am one of those consumers, and I am having trouble deciding whether to monitor myself.   I recently received a free small box, 2” by 5”, courtesy of  Castle Connolly Ltd, a health care publishing and consulting company given to me as a gift for serving on their medical advisory board.

The box contained a BodiMetrics  performance monitor  with the slogan “Your well-being in the palm of your hand” imprinted on its side.   The performance minitor ,  the box said on its other sides, would allow me to measure m “cuff-less systolic blood pressure anywhere anytime; to improve exercise results by optimizing my target health activity training zone;to measure fitness performance and the impact of lower oxygen environments at high altitude or undersea;  to daily track my vitals in 20 seconds to improve lifestyle and promote physical activity; to measure my temperature in 3 seconds with infrared technology;  and to measure my relaxation index using Heart Rate Variability (HRV); and to  teach breathing exercise to promote relaxation.  The box even contained  a pedometer to record my daily walking steps.
The performance monitor had 2 menu screens for general navigations, a monitor with a touch screen, an infrared temperature sensor, an internal SpO2 sensor, a home button to turn the monitor on or off, a multifunction connectors, 3 ECG electrodes, , and  neck strap hole to allow me to measure my vitals and their responses anytime anywhwere.
At the bottom of the box was a neck strap and an 18” electrical cord , one of which plugs into the device and the other into I know not what
I have 3 problems with the device.
One,  the instructions don't tell me what to plug it into, rendering it inoperable.
Two,  I am having  a hard time following the directions how to use and have frittered away an hour or so trying to learn how.
Three,  I do not want to know my  vitals, my response to exercise, my oxygen levels, number of steps taken, or my temperature.
I have asked a young geek to show me how to use it.   After he teaches me,  I will give it to him.   I am one who is out-of-step  and out-of-time with DYI technologies, which have their place but not in my space.  As for others, it's up to you, to do unto yourself what others would do unto you.


Thursday, January 28, 2016

Lack of National Commitment over Health Reform

Have you ever wondered about the lack of national commitment to health reform?  
Well,  I have. 
After all, this nation committed itself to developing the atomic bomb,  to putting a man on the moon,  to winning the Cold War, surely should be able to committee itself to national health.
Why not health reform?    Our health  affects us all, and we all want to retain our health , prevent disease, and ward off death as long as we can. 
I have come to these conclusions.
One,   health reform is a personal, not a collective matter. Given human nature,  most of us  act out of personal self-interest rather than collective interest. And as Adam Smith pointed out in the Wealth of Nations,  personal economic self-interests raises everybody’s  overall interests.
Two, with health reform,  there is no external threat to our nation’s personal health, no competition with other nations related to our personal existence or health or survival.
Three,  health reform, Obama style, is dedicated to covering 14% of the uninsured population,  but when it was launched, 86% were satisfied with their health care.  Those numbers persist to this day.
Four,   human behavior is predicated on the notion of the survival of the fittest  and the winnowing out of the less fit.  In a free enterprise competitive society,  neither compassionate liberalism or compassionate conservatism works very well. This truth is too bad, but it exists.
Five,    in  a pragmatic center-right capitalistic nation,  results are more compelling than rhetoric,   no matter who noble  or eloquent.  Reform is expensive, in the neighborhood of $1 trillion spread over 10 years, and its results in improving health so far are not impressive.  As a cynic said, “when they say it’s the principle and not the money, it’s the money.”
Six,  lack of bipartisan agreement  about how to go about introducing reform  or how to calculate its long-term costs,hampers its implementation in an impatient nation, that developed an Atomic Bomb in 5 years,  won World War II in 4 years and put a man on the moon in 7 years.
Seven,   somehow the scientific approach -  computer-collected metadata as a means of guiding and paying for health care, though  objective and admirable in its way  because of its lack of emotional, moral, and political content,  lacks humanism  and individualism and freedom of choice,  and doesn’t sell well.

Human nature and national nature, be not proud.   But sometimes telling it the way it is rather than the way it ought to be clears the air and clarifies the situation.

The Future of ObamaCare
The future of ObamaCare may not be what it was cracked up to be -  upwardly mobile, virtually connected,  increasingly digitally and data-driven,  interconnected and interoperable,  more collaborative and cooperative,  less and less costly,  more and more efficient and effective,  and generally, better and better in every way.  At least, the future  hasn’t worked out that well  so far. Maybe, given more time, it will.
What follows are 11 assessments of how well ObamaCare is working out 7 years after its passage and implementation.
One,   insurers are taking heavy losses from the 13 million who have signed up for the health exchanges.  UnitedHealth, the biggest of them all,  is pulling out of the exchanges after losing $450 billion last year.  Other major insurers may follow,   and more than half of the insurance co-op have failed.
Two,  premiums and deductibles are spiking,   often as much as 30% to 40%,  though the increases are variable and average about 10%.
Three,  the number signing up on health exchanges have gone up by 13 million,  40% less than the originally projected 20 million,  at the cost of $56 billon, expected to double  this decade, and   11 million of the 13 million are subsidized and are sicker than anticipated, driving up costs even faster than anticipated.
Four,  the United States continues to spend 40% to 50% more than other developed nations,  We  lag behind them in longevity and infant mortality rates, but we are ahead of them in access and results of diabetes,  cardiovascular, and cancer treatments.
Five,  the skeptical American public opposes ObamaCare  by consistent margins of  5% to 10%, with a slight majority favoring a fix rather than repeal and replacement, depending how the question is asked in polls.
Six ,  a clear majority of physicians look with disfavor upon ObamaCare, with 26% giving it a D or F grade.  Physician morale is low, physician engagement with the system and patients is declining,  and physician shortages are growing.  Many physicians feel they are not part of the health reform conversation, and significant numbers are leaving traditional practices or are not accepting patients covered by  3rd party insurance to participate in “direct” or “cash-only” arrangements .
Seven,   the nation’s health care information system is faulty, clunky,  and inadequate. Despite widespread  physician and hospital adoption of electronic health records,  information systems  are not interoperative,  not user-friendly,  not effective in advancing quality, and are either counter-productive or distracting  in patient-physician relationships.
Eight,  ObamaCare has not lived up to its promises of lower premiums, higher quality,  and patient retention of their doctors,  health plans, and hospitals.
Nine,  the American middleclass is particularly unhappy with the health care system because of a variety of factors, - affordability,   accessibility,  unpredictability , and complexity.
Ten,  partisanship  and disagreements among  the major politic parties   cast a pall over the future of ObamaCare and how to fix its problems.  Repeal, replacement,  elimination of individual and employer mandates, and reduction of regulations are possible and may to imminent.
Eleven,  the  technological innovations  being offered by the Centers of Medicare and Medicare Innovation -  data-based algorithms to guide care,  a shift to  value, evidence-based  reimbursements, physician-hospital bundled capitated payments  rather than individual  fee-for-service are on the horizon but are controversial  and do not sit well with providers.




Wednesday, January 27, 2016

Hearts vs Heads
The Congressional Business Office (CBO) has estimated ObamaCare sign-ups in the final, third,  and last sign-up period in the Obama administration will fall 40% short of what the CBO originally projected,  13 million rather than 20 million.   Of the 13 million who signed on,  11 million received subsidies.  These subsidies will cost $56 billion in 2016 for a total of $56 billion,  with the $56 billion expected to double within the decade, if ObamaCare remains intact.   This sign-up shortfall poses political challenges for Democrats and other health law advocates and will leave an estimated 30 million uninsured.

O say what can you say
Of debate’s early sway
Of paid-for coverage
vs  excess gov baggage

Who will the winner be
What will the costs be

Will it be the heart-felt
With blows reality has dealt
Premiums beyond control
Beyond people’s bankroll
But who feel for the uninsured
For what they have endured

Or will it be the hard-heads
With their dread of the feds
Who can’t make promises
To calm doubting Thomas’s

The hearts  believe in their heart
The deal  will never  come apart
A government  deal is a sealed  deal

No one should go without a free meal.

They know  those subsidized 
Are  really hostages in disguise
The public will never allow
The Left  to the right to kowtow.
Or permit those on the mean streets,
To go without special federal treats.
But alas, those with cool heads
Say Obamacare is in shreds.
The  solution is to scrap the health law.
By swinging a solid right to the jaw.



The Law of Trump in Iowa

This the law of Trump in Iowa, that only the
  strong shall thrive,
That only the weak shall perish, and only the fit,
Dissolute, damned and disrespectful,  insulted,
  defamed  and slain,
This is the Will of Trump in Iowa- Lo, how he
  makes it plain.
Before the debate , in a solo game, sat Dangerous
   Don McTrump,
And watching his luck was his light-o-hate, the lady
   Megyn  he knew as a frump.
He was grim and cold, he was bad and bold

He was dangerous Don McTrump

And while dangerous Don was a-playin’ his hand

And keeping his mind on his game

You could see standing back  with the TV glare  in her eye

Was the lady Megyn he knew as a frump.

Then out of the night which was twenty below

And into the din and the glare

A man called Ted Cruz swaggered in

And his face was filled with malice

Now he looked all around until he had found

And his eyes they burned

On dangerous Don McTrump

Then suddenly wham! All the lights went out

And a voice cried “Exit , I  must!”

And then a woman screamed and a voice rang out

And somebody fled before the debate

And then the lights flashed on

And the Fox News posse

Came a-crashin’ through

They raised their voices and they yelled

“Which one is dangerous Don Mc Trump?”

And then somebody said “well hi there!”

And skipped across the floor

A-one, two, skip, hand across lip

Right out through the open door

Now was it the stranger Cruz  a-takin’ his leave?

Or the lady known as Megyn the frump?

It was nobody else in this whole wide world

But dangerous Don Mc Trump.

Courtesy and Apologies to Robert Service (1874-1958). The Law of the Yukon and Dangerous Dan McGrew

Tuesday, January 26, 2016

Health Reform and  Heart-Head  Rhetoric
If you are not liberal at twenty, you have no heart; if you are not conservative at forty, you have no brain.
Winston Churchill

I often think it’s comical
How nature does contrive
That’s every boy and every gal,
Is either a little Liberal,
Or else a little Conservative!
W.S. Gilbert Iolanthe II

I see by the various polls  that  roughly 60%% of Democrat  millenials are  voting for Sanders  and about 60% of  the middle class, 45 and older,  are voting for Clinton.   Similar percentage align themselves for retention or repeal of ObamaCare.
What’s going on here is dualism.  The young are idealistic.   The middle class and older folks are realistic.  Or, to put it a little differently.   The young are all heart, the older  are all head.
Young millenials find themselves in a bind.   They may be idealistic,  but many cannot find a job.   Why not, then,  vote for a Democratic socialist?   He promises a free college education and free health care, both largely at someone else’s expense, and maybe,  just maybe, a job at rebuilding the nation’s infrastructure.   Besides,  Medicare-for-all has a nice ring to it.
Somewhere in between are 75% of voters,  namely, the non-millenials, split between liberals, independents, and conservatives.   These non-millenials  have been around the block, and they have seen the consequences of liberalism – the worse recovery from a recession since World War II with a sluggish 2% GDP growth, a 10% drop in wages and personal wealth, and a increase in health premiums of 20% to 40% in some states.
On the other hand, they have witnessed a  decline in the uninsured from 15%  to 1o%, from 48 million to 30 million, of the population  in round numbers.  As a fair-minded people,  they know this decline is not inconsequential.
Which brings me to the  nub of the health-heart-head problem – whether to retain or repeal ObamaCare?   The answer, it’s fair to say,  is still very much up in the air. 
If you retain the law,  the 10 million who have been subsidized  and the 10 million who have taken refuge in  Medicaid are safe from those hard-hearted conservatives.
If you repeal the law, you may return to a more prosperous economy, with smaller government, less taxes and less regulations,  more choice of doctors with lower premiums, and a more hard-headed approach to the limitations of government and its excessive spending and budget deficits.
But what about those 10 million souls who the government has subsidized to give them access to health insurance?   Surely you can’t throw them overboard 
In this setting,  the conservatives  have began to formulate their alternative to ObamaCare. In general,  conservatives and Republicans have a six-point plan:
 1) Retain employer coverage for Americans, half the population.
 2) Offer tax credits for all who qualify.
3) Assure continuous coverage protection regardless of place of employment.
4) Reform Medicaid by allowing states to handle their distinct problems. 
5) Reform Medicare for new members, by allowing them to join the old Medicare or enter the new managed Medicare ranks.
6) Expand  health savings accounts to allow workers to pick and choose and negotiate their choice of plans and set aside unspent health dollars for a rainy day.  (Lanhee Chen and James Capretta; “Instead of ObamaCare; Giving Health-Care Power to the People,: WSJ,  January 25. 2015).
This plan and other plans  rely on hard-headed approaches to health reform.   The plans promise to cover just as many people as ObamaCare, but it is still not clear specifally  how they would handle those already  subsidized by government.
Therein lies the political rub, the choice between heart and  head.

Monday, January 25, 2016

The Making of a Health Reform Nuclear Reactor
c=speed of light
Albert Einstein, Theory of Relativity, 1905

Like most health reform investigators, I am always in search of metaphors.   In this case, the metaphor is  e=n/c2, an analogue of Einstein’s e-mc2.
e= energy
n =nucleus  
c= speed of reform

e is the energy of the American democracy, characterized by entrepreneurial dynamism and robust economic growth, both waiting to be unleashed.
n is the nucleus of the American nation,  and its freedoms, guaranteed by  the Constitution and the Bill of Rights, and relatively free of  government coercions .
c is the speed of health reform, which has been halved by the weight of government regulations  and market resistance.
In effect, the health reform law has split the nation’s nucleus into two halves - one commandeered  by centralized  government, the other countermanded  by decentralized market forces.
In both halves of the nation's nucleus, experiments being conducted, but results of the two  has yet to fuse.
On the federal  half of the nucleus,  experiments include:   Individual and employer  mandates,  Centers of Medicare and Medicaid Innovations with  accountable care organizations,  medical homes,  value care and population health ,  precision medicine, bundles of care based on episodes and  continuums of care,   multiple government –health systems-hospitals-physicians collaborations ,   government health exchanges, exchange co-ops. 
On the market half of the nucleus, these experiments include -  Free market care,  regional integrated health organizations,   retail clinics, urgicare centers,  surgicenters and other diagnostic and treatment centers,   focused factories, and numerous other  consumer-oriented and empowering  entities .
Lack of Critical Mass
What the two halves lack is  strong enough particles  to bombard the nucleus  to achieve critical mass to sustain a health reform   chain reaction, which in the government’s case is sufficient  new health exchange members to make going forward feasible  , and in the market’s case  adequate political support to make their brand of reform  possible.
Critical mass is essential to make a nucleus chain reaction possible,   but a nuclear  reactor is needed to control the energy release, whether that is uncontrolled government spending or free-market excesses.
Needed: A Nuclear Reactor
What is needed is some sort of nuclear pile to dampen the speed of reaction in one case and to accelerate   it in the other case.    
Most nucleus experts agree that modulating and monitoring   force must be some sort of computer-interpretative device or group of devices  that is simple and useful  and collaborative  and acceptable enough to bring the two sides together in a workable mass. 
That group of devices may  the  Free Health Interoperative Resources (FHIR) movement and the Argonaut Project  that brings together organizations  with common standards with relevant metadata that is collected on the front-lines of care from clinician -friendly electronic health records that are useful,  relevant , non-intrusive,  and produce results of value (see David Shaywitz, MD, PhD, “The Last Best Chances to Achieve Interoperability,” The Health Care Blog,  January 2015, and Richard Rhodes,  The Making of the Atomic Bomb, 1986, Simon and Schuster.