Sunday, January 27, 2013

"Costs to the health care system" What does that even mean?

Almost everyone, not just health care policy wonks, talks about costs to the health care system.It seems that we are speaking about everything related to health care,the doctors,the labs,the hospitals, the physical therapy,the medications used.etc,etc.

When I recently got a MR of my pelvis to evaluate severe groin pain, I saw an orthopedist,who billed me and then I received a bill from the Imaging center and one from the radiologist. For illustration let us say that a total of 2500 dollars exchanged hands. If we consider the three entities who billed me they all received payments. The part of the health care system they represented incurred no net costs,just the opposite. As in typical transactions one man's cost is another person's pay check.

 Since all these elements of the system received money who can we say bore the cost? So should we consider the payers as part of the health care system? That appears  to be a strange way of looking at transactions.If the payers are included in what we mean by the system then does not everything nets out.Payments made by me and what ever insurance I have (private or from CMS) went to another part of the system ( that is if we include the payer as part of the system).

So what do we mean when we say costs to the health care system? I suggest what is really meant is that someone is paying for the service and when we say reduce costs to the system we really mean that we are reducing the amount that someone paid for health care goods or services.Further the reason there is so much talk about that is because much ( if not most) of health care is paid for in part or completely  by someone's else money and that most of the talk generated about reducing cost to the system is by those other people.

When more is spent on housing or purchasing automobiles why do we not hear cries of alarm about excessive costs to the house building system or the automobile manufacturing system. In fact ,there is more than a little panic expressed when home sales or automobile sales fall and then there is  talk about inadequate aggregate demand  and perhaps the need for a goverment stimulus. When I buy a new car, is that a cost to the automobile industry or a small step towards boosting the GDP. If and when the mystical cost curve of health care is finally bent downwards, will we be hearing talk about the need for goverment action to bolster a falling health care system?

Thursday, January 24, 2013

Goverment imposed HIT a bust for health care but good business for the cronies


 Background: Part of the 2009 stimulus bill was a program (called HITECH) that  provided 27 billion $ to subsidize the purchase of electronic health records systems by medical practices but with certain conditions of use.

If anyone believes that the salvation of health care in the country ( or Great Britain for that matter) is in the electronic health records they should spend two minutes and read this information packed,insightful commentary.

First of all, the Rand corporation is backtracking on the glowing projections it has made regarding cost saving by the establishment of electronic health records.Rather than the 77 Billion $ in savings they projected they now admit it cost money-not saved money.The Rand study was widely quoted as demonstrating what great things EHRs would bring.

Ask almost any practicing physician who is taking time away from patient care to unravel and master the so-called "meaningful use" requirements how well the program is working.

The highly touted HIT program for the British NIH was a fiasco and the government has admitted as much and is stopping the program.Both the VA and the Defense Departments Electronic Health Records have been the target of well deserved criticism.

The following quote from John Goodman's health Policy Blog which is linked above talks about the bottom line and how the Mafia Rule serves us well again.

 "RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005."


So part of the stimulus bill was to take tax payer money, strong arm and sweet talk physicians into  purchasing computer systems which turned out to decrease their efficiency in clinical care but may increase hospitals proficiency in billing ,saved CMS no money but increased the revenue of certain well connected purveyors of electronic records systems.In short, by today's legislative standards a very successful program.

H/T to Paul Heish and his blog FIRM see here.

Cerner corporation has profited greatly from HITECH. See here for a blog entry from the InformaticMD at Health Care Renewal which discusses Cerner's activities in Great Britain and the NHS monumental failure in electronic health records.

Monday, January 21, 2013

Who wrote Obamacare and where is she now?

Who wrote Obamacare? Of course, no one person authored the entire lengthy statute but if one person could be singled out as playing a role greater than any other person that would have to be Liz Fowler.

At least that is what Senator Max Baucus,from whose committee the bill arose, said in the following quote:

 “I wish to single out one person, and that one person is sitting next to me. Her name is Liz Fowler. Liz Fowler is my chief health counsel. Liz Fowler has put my health care team together. Liz Fowler worked for me many years ago, left for the private sector, and then came back when she realized she could be there at the creation of health care reform because she wanted that to be, in a certain sense, her profession lifetime goal. She put together the White Paper last November–2008–the 87-page document which became the basis, the foundation, the blueprint from which almost all health care measures in all bills on both sides of the aisle came,”

Elizabeth Fowler worked with Mr. Baucus previously and then became a VP with Well Point and then back to Baucus to play the major role in writing Obamacare and now has left government "service" to have a VP job at Johnson and Johnson. That's right ,a former VP of the largest health care insurer,helped write the bill that made almost everyone buy health insurance and if they could not afford it a government subsidy would help them buy insurance. Read more details of how Washington manufactures social justice here.

Not only did she help write the law the Obama administration selected her to play a major role in the implementation of the law. See here for details and this quote from that link.

" Clearly, this is a telling indictment of the health care law itself, strongly suggesting that it was constructed by the Obama administration -- as some progressives argued -- as a massive taxpayer-financed giveaway to private insurers like WellPoint. And let's be honest: In investment terms, Fowler has been a jackpot for the health industry. The industry maximized her public policy experience for their own uses when they plucked her out of the Senate. Then, having lined her pockets, they deposited her first into a key Senate committee to write the new health care law that they will operate under, and now into the administration that will implement said law."


So, Obamacare as a giant pork barrel piece of legislation or as leaders at ACP and AMA told us as a giant step forward to provide quality healthcare to "almost all" and further social justice.Cui bono.


Addendum; Added 10/2/14 James Yandle and his grandson (Adam Smith, yes, that is really his name) have devoted a chapter to what they consider the most  significant Bootlegger/Baptist story of our time, Obamacare in their book "Bootleggers and Baptists,-How economic forces and moral persuasion interact to shape regulatory politics"..


Friday, January 11, 2013

45 years after receiving Med school diploma, I realize I am an unethical physician

I had thought for the past forty plus years that by acting as the fiduciary to my patients and by striving to help them,not harm them and respect their autonomy as individuals I would be an ethical physician. However, in recent years I have learned that by my failure to accept the egalitarian  philosophy and to strive for social justice and to act as a steward to society's medical resources, I have fallen far short of the medical ethical ideal and to act as is now thought appropriate for a medical professional.

I suppose I owe gratitude to the internists from both Europe and the United states whose combined efforts lead to the publication of the New Professionalism as explicated in  A Physician's Charter which made clear to me my ethical lapses. The Charter did not merely reaffirm the appropriate behavior between a physician and a patient but it announced how a physician should behave "towards society". 2012 saw the tenth year anniversary of its publication and I commented here regarding that achievement.

I cannot be an ethical physician because I find the concept of social justice to be vague and imprecise and open ended , a term that can be used to rhetorically justify any and all programs to redistribute and which lacks well defined (I argue undefinable) rules to determine exactly what is just.I cannot enlist to work for a concept that has no unambiguous definition and lacks anything resembling operational rules as to how to decide what is just in that formulation.

I cannot be ethical because I find the justice of redistribution to be antithesis of the justice of freedom and as best I decipher the meaning for many of  social justice it is that is  the justice of redistribution.

I cannot be ethical because I believe the concept of physicians as stewards of society's resources is sophistry and is bogus on multiple levels and is a dangerous notion. First of all, society does not have resources. there is no one named society . Society does not choose and society does not own. Individuals choose and individuals own.If one accepts the idea that individually owned assets are part of a societal pool, the next step is to correct whatever distributional inequality some observer feels is ripe to redistribute to mitigate some alleged or real inequality. As long as individuals are free to act in their own self interests within the limits of a democratic country there will be an endless array of inequalities that beg for correction in the eyes of the egalitarian.

I cannot be an ethical doctor because I consider the notion of steward of medical resources of a collective owned ( in some open ended, undefined sense) as a means or a mechanism to control medical care. The concept is both bogus and potentially dangerous.I do not believe that the intent of many of the stewardship advocates is that physicians will  each individually act to conserve resources according to their own assessment of how best to conserve or preserve simply by not ordering  "low value" tests and procedures. Rather we are talking about elite supervisory stewards who through some mechanisms such as cost benefits analysis will provide guidelines through the adherence to which the individual physicians stewards can accomplish collectively the preservation of society's resources and move towards greater social justice ends not achievable through what they believe the archaic and socially destructive selfish machinations of the physician- patient dyad.Doctor,we realize you are too busy and your capabilities too limited to do much personally to conserve the collectively owned resources and further justice but if you just follow the utilitarian based,cost effectiveness guidelines that will suffice.

I cannot be a ethical physician because of my objections to the egalitarian philosophy are so wide and so deep and that I believe the notion of redistribution is simply put a very bad idea. Why so?
Wealth is not created by redistribution and the enterprise of redistribution knows no ends. there will always be inequality of one sort or another along some scale of comparison.  The hubris of those who see an inequality along some axis presume that they know somehow to realign things to make things better (or more equal) as measured by some collective aggregate is more than I can tolerate. My priors are so strongly pro freedom that  a philosophy based on limited of freedom  is not acceptable to me.

I cannot be a modern, ethical physician because of my views about the very core of egalitarianism which included the notion that inequality needs to be corrected by government action.This assumes that the government can act as a disinterested agency capable of rationally correcting market failures and acting in the public interest and carrying out the public will.  All of that is an absurdly romantic notion of how the world works. It is a view that folks such as Jefferson and Madison understood well but too many people have either forgotten or never understood and has been replaced by the 10th grade civics class notion of how government works. If you believe that government entities are collections of individuals acting in ways to achieve outcomes consistent with their own interests and often those of special interests you will not buy into the bogus notion that justice will served by governments acting to rectify inequalities .

If you buy into the basic outlook and beliefs of classical liberalism ( i.e.libertarianism) you cannot be an ethical physician if that definition of ethical includes the mandatory acceptance and practice of egalitarianism.


Though I cannot  be a ethical physician according to the ethical principles devised by the authors of the new professionalism and the medical ethics of the American College of Physicians at least I can hope that when father time and apoptosis  take their toll on me to the point when I need medical care  there will be physicians who have the ethical stuff to act as stewards and be sure that my personal interests will not over ride those of society.

Thursday, January 10, 2013

Obamacare 's IRS rules make offspring under 26 but not spouses covered

 If you thought the unfolding consequences (unintended?) could get no more  ridiculous and socially unjust , stay tuned as the rules making ACA operational are continuing to be written and the trip down the rabbit hole  gets stranger and stranger.

See here for the latest absurdity of Obamacare. The IRS has proposed (but told business they could rely on what they said at least for the time being) that employees are covered in regard to the mandate for affordable health care and their less than 26 year old children but not their spouses.

Quoting from the NYT article linked above:


"The law says an employer with 50 or more full-time employees may be subject to a tax penalty if it fails to offer coverage to “its full-time employees (and their dependents).”

Employers asked for guidance, and the Obama administration provided it, saying that a dependent is an employee’s child under the age of 26."

Monday, January 07, 2013

At a BMI of 22.6, I need to gain some weight

I need to gain some weight because of a recent meta-analysis (see here) that informs us that folks who are "over weight" (BMI of 25 t0 30) have a lower all cause mortality than folks who are what we used to call ideal or normal weight ( BMI of 20-24.9). It gets even better, Folks who have been derided and labelled as sloths by their health care providers because of their BMI in the range of 30 - 35  have a Hazard ratio of 0.95 ( CI .88-1.01) .At 5 feet 11, I look forward to gain up to 210 from my scrawny 163. One of my new year resolutions is to act immediately on the basis of the very latest meta-analysis since:1) meta-analyses occupy the tip top of the evidence based medicine hierarchy and 2) another meta-analysis may soon appear contradicting the other one and you loose your opportunity to improve your health.

 Since we humans are pattern seeking , story telling animals the authors try and tell a tale of how the results may be explained . One suggestion- overweight people may go to doctors sooner.This is likely as chubby people love to see their doc to be told they need to loose weight.

It was not long ago that another meta-analysis found that being even a "slight amount" of overweight increased one's risk of dying.See here.

So even a little overweight is bad or a little or even a little more overweight is good. Which is it?

The following quote by an economist, FA Hayek, was, I believe, aimed at central planners of the economy but I suggest that maybe we all would be better off if the public health planners might listen as well as they go about telling everyone how to eat and what they should weigh and what size sodas they should be allowed to purchase.


"The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design."

And to begin the new year with one more of favorite quotes. It is supposedly by an attorney cross examining an expert witness. 'Doctor, were you wrong then or are you wrong now?