President Obama’s Holier Than Thou Insult

I am holier than thou.

Isaiah 65.5

The only gracious way to accept an insult is to ignore it; it you can’t ignore it, top it; if you can’t top it, laugh at it; if you can’t laugh at it,  it’s probably deserved.

Russell Lynes (1910-1991),  Editor of Harper’s Magazine, in Reader’s Digest, 1961

In a press conference the other day,  President Barack Obama said the GOP's "holy grail" and "ideological fixation" was repealing Obamacare, preventing millions of people from getting coverage.

"I think the really interesting question is why it is that my friends in the other party have made the idea of preventing these people from getting health care their holy grail, their number one priority. Their unifying principle is making sure 30 million people don't have health care."

“As they continue to try and prevent implementation of the Affordable Care Act, the GOP doesn't offer any of their own proposals to cover the uninsured.”

"At least they used to say I'm going to replace it with something better.There's not even a pretense right now that they're going to replace it with something better."

On the face of it,  this is a laughable, insulting, holier than you, foolish statement.

Why would the GOP commit political suicide by denying care to 30 million uninsured Americans?  They won’t. And why would they not offer alternative plans they believe to be better?  They have.

Sometimes one’s fixed ideology causes one to say foolish things in the heat of political battle and to make compromise difficult, or not impossible.

Tweet:  President Obama laughably says GOP is engaged in  “holy grail” based on “ideological fixation” to deny care to 30 million Americans.

The Mobile Device Gold Rush and Its Problems

Technology…the knack of so arranging the world that one doesn’t have to experience it.

Max Frish (1911-1981), Swiss playwright and novelist,  Homo Faber

If today’s  Silicon Valley forty-niners could solve the logistical and regulatory challenges of embedding home monitoring devices into a smart phone,  they will increase patient engagement and outcomes. The gold rush is on and the spoils could go to whoever gets their first.

Robert Pearl, MD, “Technology Could Put Health in the Hands of Patients, “ Forbes August 22, 2013

Put this health factoid in your mobile smartphone,

One of two adults has chronic disease it is known.

Now imagine patients with diabetes or chronic heart disease,

Phoning from home ECGs and blood glucoses to MDs with ease.

Smartphones can transmit data from home monitoring devices,

Half of  Americans own or can buy smart phones at low prices.

Why should people with these diseases not go mobile?

Why not make this mobile technology information global?

The reasons why not are logistical,

And are not that terribly mystical.

Doctors don’t have time to look at thousands of cardiogram tracings,

For the millions  of new health reform patients they will be facing.

The FDA will label data sent to doctors as a “medical device,”

New regulations will cause prices to go up twice or even thrice.

Regulations will cause innovations to stutter and delay,

To Silicon Valley venturists and entrepreneurs’ utter dismay.

But, says the Valley crowd, mobile devices  are already out there,

smartphone glucose and heart monitors for patients’ disease  care.

How can regulators the promises of new technologies postpone,

When home monitoring device are already connected to smartphones.

But alas, smartphone technologies from out of the blue,

May simply be  too impractical at present  to be true.

If only  we could arrange the medical and regulatory worlds

In order to allow those smartphone technologies unfurl.

Tweet:  Glucose and ECG monitors sending  data to doctors via smart phones are commercially available, and could transform treatment of disease.

Obamacare and Health Exchanges: Four PowerPoints of View

The choice of a point of view is the initial act of a culture.

Jose Ortega y Gasset (1883-1955), The Modern Theme

PowerPoint presentations,  a Microsoft innovation introduced in 1990, have  had an outsized cultural impact among speakers and audiences.   PowerPoint is easy to load on a computer,  gives an immediate structural outline to a talk, and saves a lot of time presenting and summarizing concepts. You can rarely attend  any conference or hear any speech without watching  PowerPoint in action.

Powerpoint is not without critics, who have called its overuse  “Death by PowerPoint,”  “BulletPoint Poisoning,” “PowerPoint Rangers,” “SlidePoint Abuse,”  and “PowerPoint Hell.”   Pentagon officials have forbidden its use and insist upon oral presentations without use of slides.

Nevertheless, PowerPoint is useful for quickly and cogently presenting one’s point of view.

Here, I shall use a print form of Powerpoint, with bullet points to present four points of view health exchanges,  the lynchpin of Obamacare’s implementation strategy.   These points of view appeared in today’s New York Times under the title of “Sunday Dialoague: Blocking Heath Reform,  readers discuss Republican efforts to  undercut Obamacare.

How Health Exchanges Improve Health Insurance, Jon Kingsdale, managing director of the Wakely Consulting Group, who helped establish health exchanges in Massachusetts

·        " First, they will provide individual consumers something new: one-stop shopping with a side-by-side comparison of health plans. By standardizing coverage, patient cost-sharing, pricing, quality and service metrics, exchanges make informed choice of health plans easy. "
 

·         "Second, they will steer competition in socially beneficial directions. By empowering price-sensitive shoppers with information, they will put pressure on premiums. This can be further enhanced by the exchange’s own effort, à la Walmart, to press health plans to improve price, quality and service in return for “shelf space” — that is, access to the stores’ customers."
 

Why Health Exchanges Will Get Off to a Rocky Start,  James G. Russell, Alexandria, Virginia,  affiliation not known

·         "First, the Affordable Care Act was passed during a brief period of Democratic supremacy over almost universal Republican opposition. Republicans have no interest in the success of what they call Obamacare. They control many of the levers of government and can do much to impede the health law"
 

·         "Second, this complex law relies on persuading young people to take the positive step to buy insurance that has been heavily overpriced for them in order to underprice insurance for older people. The stick to encourage them to sign up is a trivial fine starting at $95. These are the same young people who are already burdened by Social Security and Medicare taxes to finance benefits for their elders that they do not expect to receive equally in their old age, and who often feel that health insurance is an unaffordable luxury."
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There you have it – four bullet point  but necessarily bullet proof reasons health exchanges might improve choice of health plans and might encounter stormy weather.

Tweet:   The reasons for success or failure of Obamacare health exchanges are here reduced to four bullet points based on one’s political culture.

Who Killed Health Reform?

A system controlled by the insurance companies or hospitals or government will kill us financially and medically – it will ruin our economy, deny us the health services we need, and undermine the important genomic research  that can fundamentally improve the practice of medicine and control its costs.

Regina Herzlinger, PhD, Professor,  Harvard Business School, Who Killed Health Care? McGraw Hill, 2007

In her pre-Obamacare book, professor Regina Herzlinger  of Harvard Business School,  argued that these prominent groups  were cripplingUS health care:

·         Killer Number 1: the Health Insurers,  Death at the Hands of a Dysfunctional Culture

·         Killer Number 2: The General Hospitals, Death at the Hands of Empire Builders

·         Killer Number 3:  The Employers, Death at the Hands of a “Choice” of One

·         Killer Number 4, The U.S. Congress, Death at the Hands of Those Chosen to Represent Us

·         Killer Number 5,   The Academics,  Death at the Hands of Elite Policy Makers
 

Herzlinger’s solution

·         Create a consumer-driven system, focusing on responsible, informed consumers

·         Require everyone to buy insurance, using tax-sheltered income.

·         Have government subsidize those who cannot afford to buy insurance.

·         Let physicians bundle care as they wish and to quote their own prices.

·         Require publication of data on performance of all hospitals and physicians.

·         Adjust prices for risk.

·         Let information flow.

·         Let  competition flow across state lines.

·         Let medical business entrepreneurialism bloom.
 

It’s more complicated than that and will require government oversight.   But that’s the essence of it.

Two New Killers – Job Creation and Physician Creation

In the post-Obamacare era, two new killers have emerged on the health care horizon.

These are:

·         Obama’s health law is a job killer.   Most observers, except for Obama and his advisors, e.g. Jonathon Gruber, “Will the Health –Care Law Help Small Businesses, YES: Firms Will Have Affordable Options, “ WSJ, August 19, 2013), agrees. The  pervasive uncertainties and onerous regulations inherent in Obamacare will hurt business Growth (Will the Health-are Law Help Small Business,”NO: Harder for Small Firms to Grow,} WSJ, August 19, 2013).    

Thomas Stemberg, founder and former CEO of Staples, in another WSJ article (“A New Law to Liberate American Business,” August 22, WSJ) says, “ The current regulatory regime just kills more jobs and stifles the formation of new small businesses – the life blood of job creation in our economy… if the president and Congress are serious about creating jobs, they must take seriously the job-killing regulations that are holding job creation back.” A May 2013 Heritage Foundation report, “Red Tape Rising,” found that new regulatory costs added in 2012 totaled $23.5 billion.  Obamacare alone has generated nearly 20,000 pages of new regulations.

·         Obama’s health law is a physician supply killer.  America is in the midst of physician shortage – a demand-supply crisis – just as 30 million new Medicaid and previously uninsured enter the market in 2014  and 78 million baby boomers are becoming  eligible for Medicare over the next decade.  Yet,  at the moment, the US is  short 50,000 primary care physicians, a number that will grow to over 100,000 after 2020.  

      Obamacare does little to address this shortage – to correct the SGR (Sustainable Growth Rate) formula, which this year threatens to cut physicians Medicare reimbursement by over 20%; to institute malpractice reform, which is costing the nation as much as $100 million because of the practice  defensive medicine  to avoid frivolous law suits;  to expand the number of primary care residency programs, which are needed to  train  the physicians required  to serve millions of anticipated new patients;  to increase physician reimbursements for Medicaid patients, which are now 58% of private pay, and Medicare, 80% of private pay.  

Tweet:  Obamacare has suppressed hiring of full-time workers and has failed to offer incentives or solutions to relieve the physician shortage.

Out of Sight, Out of Mind

And when he is out of sight, quickly also is he out of mind.

Thomas a Kempis (1380-1471)

When it comes to medication adherence, what we’re doing isn’t cutting it. Though as individuals we may feel ill-equipped to transform patients into “pill people,” as a community we face an opportunity to develop better ways of caring for people even when they’re out of our sight.

Lisa Rosenbaum, MD, and Willima Shank,  “Taking Our Medicine – Improving Adherence in the Accountability Era, “ New England Journal of Medicine, August 22, 2013

“We’re all in this together” is a familiar Obamacare theme.  If  physicians, nurses, hospitals, pharmacists,  and other health care community members together would collectively  provide “coordinated” care,  outcomes would improve.   

How?

·         By shifting physician reimbursement from fee-for-service to collective capitated payment to patient outcomes. 

·         By penalizing hospitals financially when they are readmitted because of non-adherence  to treatment plans or life-style misbehavior.

·         By  not caring for patients “out of sight and out of mind “ by not  controlling and tracking patient behavior outside the physician’s office and outside of the hospital. 

·         By improving patient adherence to good health principles through “Patient-Centered Medical Homes” (PCMHs), Accountable Care Organizations” (ACOs), and Bundling Bills (BBs) holding providers accountable for total costs and outcomes.

It’s as simple as the ABCs or the  PCMHs,   the ACOs, or the BBs,  or the IPAB (Independent Payment Advisory Board), who would enforce it all.

Or is it?   Americans are a notoriously independent people.   They think they know what’s good for their health, even if health professionals do not endorse it.    An estimated 1/3 to to ½  of patients do not follow prescribed medication regimens. This non-adheremce  may cost the US $100 billion to $290 billion annually.    You can decrease these costs  and non-adherence  problems by prescribing generics,  by tracking use at pharmacies, by recommending weekly pill boxes to minimize forgetfulness, or by home visits to monitor compliance.  

 On top of these factors is the general distrust of government policies that interfere and intervene into patients' daily lives.    There are practical and deeply psychological issues involved when you start tinkering with a culture that treasures independence and personal choice to live as one pleases. 

Besides, how  can you or do you predict what patients will do, once they leave your sight and who enter their own mindsets?   How  do you go about penalizing physicians  for patient misbehavior and non-compliance once the patient is out of sight. This is beyond the realm of new payment mechanisms or predictive algorithms.  This is about transforming a culture.

Tweet:  Controlling patients' misbehavior and non-compliance with  treatment plans is difficult once the patient is “out of sight and out of mind.”

 

Shootout  at  the Goverment's O.K. Corral

Shutting down government because of Obamacare is a bad idea.

Such a shootout would surely bring the GOP down to one knee.

Going down to the other knee would be letting the ACA  proceed,

without its many egregious faults to concede or to  impede.

Technically defunding Obamacare is not tantamount to a government shutdown,

But Obama would portray defunding and shutdown as part of same showdown.

Delay for a year should be the name of the strategic game,

Democrats and Republicans could then share the blame.

That would give time to figure out how to compromise,

Now, wouldn’t that be an overdue pleasant surprise?

A delay is better than a gunfight at the government corral,

Such a shootout would not be good for national morale.

Tweet:  Shutting down government secondary  to defunding Obamacare is a bad idea,  delaying  it for a year to seek compromise is a better idea.