A Visit with a Socialist Physician

October 17, 2011 - I visited a private doctor today in his office. He was an endocrine specialist. His medical skills, interactive manner, and thoroughness impressed me.

Towards the visit’s end, I asked, “What do you think about the current state of health reform?”

He replied emphatically,“ I am a socialist!”

I asked: “What does that mean?”

He answered without hesitating, I’m paraphrasing. But this is the gist of what he had to say.

I believe everyone ought to receive government-sponsored basic care at no cost at the point of care.

I believe general taxation ought to wholly support the system.

I believe government ought to pay for medical education and post-graduate training of all physicians.

I believe government ought to set all physician fees.

I believe government ought to end malpractice insurance.

I believe private insurance companies , Medicare, and Medicaid ought to be eliminated.

I believe drug companies and all firms in the health care product chain ought to be heavily regulated, and government ought to set their prices.

I believe the profit motive has no place in health care transactions.

I believe government ought to employ all doctors and place them on salaries.

I believe if you want more care than government offers, you ought to pay for it.

I said, “Are you going to vote for Obama?”

He retorted, “Are you kidding?”

He was all for one , and one for all, but believed some are more equal than others when it comes to paying for non-government care.

I thought of sending him a copy of my book, The Health Reform Maze. I I decided not to. The book says health care is too complicated for simple solutions, and doctors must give incentives to doctors and patients for the best care, and patients must be given freedom to choose between public and private care.

Tweet: Socialized medicine is great in the abstract. It takes profits out of medicine. Except without profits, no one can carry out their mission.

Health Reform - Vertical and Horizontal, Focused and Unfocused.

Let us honor if we can
The vertical man
Though we value none
But the horizontal one.

Wystan Hugh Auden (1907-1973), Epigraph for Poems, 1930

October 16, 2011- In the health care realm , I tend to be a horizontal thinker in a vertical world. Put another way, I’m a generalist in a world that caters to specialists. Federal policy makers think the same way. They feel broadening the primary care base will rationalize the system, make it more efficient, and lower costs.

Which reminds me of the writings of Edward de Bono, MD (1933- ), a London-based doctor who runs a think tank institute in Malta. De Bono came up the concept of “Lateral Thinking. ”

De Bono visualizes the medical landscape as a series of vertical holes. Each hole comes stacked with specialists with a world-class expert at the bottom of each hole. The trouble is, he says, that no lateral connections exist between the vertical shafts in a horizontal medical world.

Policy makers, and Obama’s government experts, call this lack of lateral connections as “fragmentation.” They claim the problem of equal access could be solved by herding primary care doctors, specialists, and hospitals together into accountable care organizations – a solution roundly and soundly denounced by even quasi-ACOs like Mayo, Kaiser, Giesinger and other integrated groups.

The solution, according to policy and Obama folks, is to reconnect the vertical holes with armies of newly trained primary care doctors. Put a primary care lid on the entrance to the vertical shafts. Make generalists better-paid than specialists. Have the cognitive doctors funnel and control referrals to procedural specialists.

The problem, of course, is: that is not the way the world works. Patients prefer to go directly to specialists, or to specialty-oriented organizations in which the primary care doctors are closely allied with the specialists.

What goes on in the real world is that hospitals developed specialty lines of service, most often related to heart, orthopedic, or cancer care. Specialists, in their turn, develop and own facilities in which they focus on one line of service – cataract surgery, joint replacements, minor cardiac procedures, hernias, rehabilitation techniques, back-pain services, diseases like diabetes, and so forth.

Regina Herzlinger, PhD, a tenured professor at Harvard Business School, where she teaches MBA-seeking physician entrepreneurs, calls those vertical organizations “focused factories.”

Here is how Hwezlinger explains these “factories.”

The American health care industry is filled with opportunities to establish focused factories, ranging from those that perform one procedure, like cataract surgery, to those that provide the full panoply of care for a disease like cancer. To fulfill the promise of focused factories, however, the industry will have to resize, that is, replace its unfocused multiple providers and redundant , underutilized technology with muscular focused factories loaded with cost-saving , quality-enhancing medical technology.

The simplicity and repetition inherent in “focused factories, “ which health care people prefer to call “centers of excellence,” is competence coupled with low costs and fewer complications.

Congress, under pressure from the general hospital industry, has outlawed physician-owned orthopedic and heart-owned hospitals. But don’t fret. Focused factories will be back in other forms – short-term ambulatory surgery facilities, non-invasive treatment centers, and centers detached from hospitals, and diagnostic and disease centers.

You can keep the vertical down or flatten the vertifal into the horizontal.


Tweet: Specialist-oriented centers of excellence, sometimes called focused factories, are proliferating across the medical landscape.

Another Obamacare Debacle: CLASS Crashes

October 15, 2011 – The demise of CLASS, a long-term insurance program, is another example of how the Obama and the Democrats, in their rush of make history, failed to think through the financial implications of consquences of key provisions in Obamacare.

The Obama administration yesterday pulled the plug on a major program in the president's health law – a long-term care insurance plan dogged with doubts over its financial solvency. Known as CLASS, the Community Living Assistance Services and Supports program was a long-standing priority of the late Massachusetts Democratic Sen. Edward M. Kennedy.

The program became a major casualty in the health care law war. It was scheduled to launch in 2013.

Although government sponsored, it was supposed to function as a self-sustaining voluntary insurance plan, open to working adults regardless of age or health. Workers would pay an affordable monthly premium during their careers and could collect a modest daily cash benefit of at least $50 if they became disabled later in life. The money could go for services at home or to help with nursing home bills.

But a central design flaw dogged CLASS. Unless large numbers of healthy people willingly sign up during their working years, soaring premiums driven by the needs of disabled beneficiaries would destabilize it, eventually requiring a taxpayer bailout.

Obama officials said they discovered they could not make CLASS both affordable and financially solvent while keeping it a voluntary program open to virtually all workers, as the law also required.

Nearly a year before the health care law passed, Richard Foster, head of long-range economic forecasts for Medicare warned administration and congressional officials that CLASS would be unworkable. His warnings were disregarded, as Obama declared his support for adding the long-term care plan to his health care bill

Health Reform and Political Musical Chairs

Every boy and every gal
Who’s born in this world alive
Is either a little liberal
Or a little conservative.

Gilbert and Sullivan Song

Your proposition may be good
But let’s make one thing understood
Whatever it is, I’m against it
And even when you’ve changed it or condensed it
I’m against it.

Groucho Marx, Horse Feathers

October 14, 2011 – We’re all a little liberal, and a little conservative, but you would never guess it from the current political musical chair game.

The game goes like this. The music starts. Liberals, conservatives, and moderates circle chairs. The music stops. Liberals and conservatives grab their chairs. The moderate is left standing.

No chairs remain for moderates in political discourse. For example, you’re either for or against Obamacare. In June 2012, the Supreme Court will decide who gets their chairs.

Health reform musical chairs makes little sense. American health care has always been a partnership between the public and private sectors. Today government programs cover 100 million Americans, private plans 200 million. Government laws say hospital ERs must accept all comers. Private physicians and institutions care for those in government plans. Medicare, in concert with the private Reimbursement Update Committee, sets physician fees. The public overwhelmingly supports NIH and academic research and physician training expenses. We endorse the VA, the largest hospital system in the Western world. We support government-subsidized community health clinics, which care for 20 million Americans.

And so it goes, the intimate intermingling of the public and private sectors.

Americans like it that way. Eighty percent of us like our private plans. We expect Medicare and Medicaid and Tricare to pick up the slack. We like quick access to high tech medicine – stents, angioplasties, hip and knee replacements, organ transplants, artificial cataracts with related devices, dialysis, and wonder drugs – and to the private doctors who administer or perform them.

We like the diversity of care systems in this vast diverse continental nation - Kaiser in the west, Mayo and Cleveland Clinics in the Midwest and beyond, Giesinger and the Boston Medical academic complex in the East, and private and academic systems everywhere.

America is a decentralized, centrist, conservative society that resists radical political policy swings. We welcome federal entitlement programs, but not at the price of roaring deficits and soaring taxes as far as the eye can see or the mind can imagine. And we are deeply suspicious of one-size-fits-all national solutions that compromise individual freedoms or smack of ”socialized medicine.”

Still we like simplistic solutions expressed as sound bites, whether shouted by the left or right, the Tea Party or the Occupy Wall Street Crowds. 9-9-9 appeals to us.

We dislike moderates who speak in nuances, or in hushed tones about compromise at the margins, much less in the middle.

The perception of Mitt Romney as a moderate is problem among conservatives. Romney has the audacity to change his position in changing times, whether it be Roe v. Wade, or health care. After instituting Romneycare,he now says that each state ought to have the option of creating its own health system, that you can simultaneously be a social liberal and fiscal conservative, and that health care is too complicated for simplistic solutions.

Last night I was listening to a PBS documentary, “The Unseen Alistair Cooke.” Cooke was a Cambridge-educated Englishman turned American citizen. He loved, understood, and relished America - our contrariness, our independence, and our love of individual freedoms.

From 1932 to 2004, when he died at age 95, Cooke crisscrossed America, by train, plane, and car, while explaining in Letters from America to his English brethren, what America and Americans were really like.

In his book Alistair Cooke’s America (Knopf, 1974), he had this to say about his adopted land.

It is a bitterly, and sometimes rousing, complicated place, this land thrashing over such incessant contradictions as control and permissiveness, the radical young and the conservative middle. The limitlessness of civil rights and the limitation of presidential power. ..While the American tradition is conservative, what it has struggled to conserve are often very radical indeed.

A still more timely reminder that the government of a free people is meant to be argued about comes form the most famous of American jurists. It gives me, at least, some hope in the outcome of our present conflicts. It is that tremendous line of Justice Oliver Wendell Holmes: A Constitution is made for people of fundamentally differing views.

A moderate wrote that passage. He kept his chair in the game of journalistic musical chairs for 74 years. We can learn something from him: moderation is no vice. It deserves its musical chair at the table of national and health care politics.

Tweet: In today's political musical chair game, there is no room for moderates like Romney, only for extreme liberals or conservatives

The Great Finesse in Health Reform- Changing The Language

One man’s words are another man’s poison.

Anonymous

We were reasonably calculating in our approach. We consciously began using the language of the marketplace, rather than the language of medicine. We began talking in terms of “providers and consumers” instead of “doctors and patients,” for example. This, of course, was and still is highly offensive to many people in medicine, and we felt the old language was almost like the language of religion, and, thus, harder to use when trying to affect widespread change.

Paul Ellwood, MD, 1985, “Life on the Cutting Edge,“ Twin Cities Magazine, 1985

1n 1988 in Who Shall Care for The Sick: The Corporate Transformation of Medicine in Minnesota, I said that words matter in health reform, that use of “providers and consumers” signaled a transformation in American medicine, and that these words werea “Grand Finesse” of American physicians, effectively distracting them from what was really happening.

I predicted physicians would become serfs of payers, physicians would be disillusioned , and ultimately, a doctor shortage would ensue.

In my book, I quoted a passage from Alice in Wonderland,

“ ‘ The question is,‘ said Alice,‘ whether we can make words mean so many things.”
‘The question is,’ said Humpty Dumpty, ‘ which is to be the master – that’s all.”

The master has become the marketplace and payers – whether they be private plans or Medicare. If you give the matter any thought at all, you will realize changing the language from “doctor and patient” to “provider and customer” changes everything.

Money becomes King. The new words reduces doctors to just another “provider,” or “vendor,” or “seller,” along with other “providers” – chiropractor, naturopath, social worker, psychologist, physical or respiratory therapist, hospital, or any other care facility.

And these words transmute patients into “buyers,” “consumers,” or “consumers.” It opens the doors for converting medicine is just another business sector that can be industrialized and standardized - the main thrust of Obamacare and its cadre of government experts.

As my 1988 book indicates, thee is nothing “new” about this conversion of medicine into just another industry. It has its real beginning with wholesale introduction of managed care into the medical mainstream in the 1970s and 1980s and continues to this day.

In an essay “The New Language of Medicine, “ in the October 13 issue of the New England Journal of Medicine, Pamela Hartzband, MD, and Jerome Groopman, MD, wife and husband and Harvard faculty members, capture the essence of the impact of the language change means.

Prominent health policy and even physicians contend that clinical care should essentially be a matter of following operating manuals, like factor blueprints, written by experts.”

They go on,

The guidelines for care are touted as strictly scientific and objective, In contrast, clinical judgment is cast as subjective, unreliable, and unscientific.

And they conclude,

The specific cutoffs for treatment or no treatment, testing or no testing, the weighing of risk versus benefits – all necessarily reflect the values and preferences of the experts who wrote the recommendations. And their values and preferences are subjective not scientific.

Medicine, by its very nature, because it involves the permutations and combinations of variable human beings and their variable relationships with different values and expectations, is inherently subjective most of the time.

Yet I have not seen a comprehensive study of large series of consecutive patients going through primary care offices showing how many of these patients have conditions to which “objective guidelines” apply.

There is another motive, seldom mentioned, behind the widespread use of guidelines – reining in physician economic behavior, particularly “clinical judgment” that benefits doctors financially.

Supposedly guidelines, by rationalizing what should or should not be done, and what should or should not be paid for, would cut the physician “greed” factor. This so-called greed may be partly unconscious. Yes, doctors profit from procedures or tests they are trained to do or order. These is what colleagues and patients expect them to do.

The guidelines may miss another critical point – doctors deeply believe what they do helps people and shows they care about patients as people, not just “paying customers.”

The words, “patient doctor,” are serious words. Human relationships matter. They are a national and human resource and should be preserved and cherished over mere “provider and consumers.”

Tweet: Changing the language from "doctor and patient" to "provider and customer" changes the fundamental nature of medical practice.

The Great Prostate Debate: “We” Versus “Me”

The public demands certainties but there are no certainties.

H.L. Mencken (1880-1956)

October 12, 2011 - The government, representing “We, The People,” is responsible for spending the public’s money intelligently based on facts. The individual citizen, “Me, The Person,” is responsible for preserving his/her health based on what he/she perceives to be in his best interest.

With PSA screening for prostate cancer, these responsibilities conflict because the screening may do more harm than good. Prostate cancer is a common, slow moving cancer. Five times more men with it than from it, and the side effects of biopsy and treatment can be devastating.

Hence, the great prostate debate – whether to screen routinely for prostate cancer with PSA testing, and whether to biopsy and treat patients with marginally elevated levels.

The debate raises other issues as well,

Medicine as a rational science,
versus sometimes irrational individual choice.

Statistical objectivity,
versus human subjectivity.

Minimalist clinical mindsets,
versus maximalist clinical behaviors.

Supposedly impersonal statistics,
pitted against very human logistics.

Cancer as a perceived death warrant,
Or cancer just another chronic disease of aging.

In the October 9 issue of the New York Times Magazine,
Daniel J. Leviter, professor of Psychology at McGill University, in a review of The Medical Mind, distills the essence of the prostate controversy with these words,

“Prostate cancer is slow moving.
More people die with it than from it.
For every 48 prostate surgery procedures,
Only one patient benefits –
The other 47 patients would have lived
just as long without it.
Moreover, the 47 who didn’t need
The surgery are often left with side effects –
Incontinence, impotence, and loss of sexual desire.
The likeliness of one is these side effects is over 50 percent-
27 or the 47 will have at least one.
This means a patient is 24 more times to experience the side effect than the cure.”

On the other hand, and there is always another side in any great debate, many doctors insist PSA screening is of great benefit, ans saves many lives. Those on the other side include urologists who treat patients with elevated PSAs, patients relieved of the anxiety of no longer harboring a malignancy, and oncologists who have witnessed malignancies caught before they spread or while in the early stages.

Tweet: Statistics from large populations do not necessarily apply to individual patiets.That's case in PSA screening and prostate biopsies.