Category Archives: Business

Medical School Rationing

Fixing Healthcare – Part 2 — Doctors

I’ve known many intelligent, talented, committed young people who aspired to become doctors, but couldn’t get into medical school. Some were resigned to their fate and used their degree in biochemistry to become medical technologists; others made arrangements to attend medical school outside the United States—primarily in the Caribbean. In one case, in order to study at a school in the Caribbean, the aspiring medical student’s parents sold virtually everything to finance her education. She’s nearly complete with her rotations back here at US hospitals and plans on serving rural or tribal underserved areas.

While we don’t have enough graduates of United States medical schools, we grant 85,000 special visas to foreign medical graduates every year because it’s a “critical shortage.” Today, roughly one quarter of all practicing physicians are foreign medical graduates. I’ve worked with many, and while their initial desire is to return home, after about six months the sports car and the arm-candy significant other appears. When I ask if their plans have changed, I’ve been told, “If I return home, I will be paid in chickens and melons. If I stay here, I will be paid in dollars. I like dollars better than chickens and melons.”

So, we import thousands of non-American doctors every year even though we have many Americans who want to study medicine but are turned away.

A decade or so ago, when more students wanted to study law, the educational industry had no difficulty in adding seats—even if they had to build new schools. Why won’t (not can’t) we do the same for medical schools?

Some claim there wouldn’t be enough residency opportunities if we graduated more doctors from US schools, yet foreign medical graduates can and do get residency positions at US hospitals. In any other industry, this might be viewed as restraint of trade.

I suggest that the goal of US medical schools should be to increase their capacity so that by 2030 ALL US residency openings can be filled with US citizens who graduated from US medical schools.

Next, I would change the entry criteria to include the following:

  1. Accepting students with a commitment to actually practice medicine; better yet a commitment to practice whatever type of medicine is in short supply, wherever needed, for at least three years. After that, every accommodation should be made to place that individual in a residency or fellowship of their choosing for which they have the talent, without a decrease in salary.
  2. While academic achievement is important, the ability to work as a team is critical. History is full of brilliant people who didn’t succeed because they could not work with others, and medicine is now a team sport—whether the person with MD or DO after their name likes it or not, they are teammates with the nurses, technologists, therapists, etc. No one is a superstar.
  3. Children of doctors or other elites should have to prove themselves more—not less—than other medical school candidates. They’ve grown up exposed to the field, often in an environment of privilege, so they should demonstrate their desire to serve, not their pedigree.

In short, we need more doctors, but our current method of selecting them is less than optimal.

Fixing Healthcare in America

First in a series

To correct healthcare and get costs under control, we must first acknowledge, then change the healthcare industry’s unique and outrageously dysfunctional business model.

  1. Physicians and other practitioners who decide which resources will be used in a hospital are often neither the direct provider, the one who pays, nor the beneficiary of the service. Basic economic rules, therefore do not apply. Medical tests, which are intended to provide information that will in some way impact the patient’s course of treatment, don’t. Many test and other procedures are ordered even when the outcome of the test will in no way affect the treatment of the patient or its results.
  2. Medical products and services are priced without any rationale. Often, prices are set artificially high in order to allow large discounts to insurance companies. This means that patients without insurance can be charged list price; eighty dollars for an aspirin or $100 for a BandAid®. Hospitals, which were once a ministry, stewardship, or public service have changed their priority to the bottom line. Some hospitals now own and operate their own collection agencies augmented by a small army of lawyers to guarantee that they collect what they have billed. This is why it is not uncommon for a small-town hospital to have millions of dollars in the bank—and still retain their not-for-profit status.
  3. And the insurance companies that get those big discounts? The hospital needs a staff of trained bureaucrats to generate the paperwork that is sent to the insurance company in order to receive payment. Payments may not be received for several months (for the MBAs out there—remember the first rule of finance—a bird [dollar] in the hand is worth two in the bush [accounts receivable]). When payment does arrive, administrative staff must reconcile the payments and file additional paperwork as necessary. All this adds to the hospital’s costs without adding any value. The insurance companies, on the other hand, are usually quite profitable, even after spending a lot of money on lobbyists. But just like Don Corleone said, “It’s nothing personal, it’s strictly business.”

So, what do we do?

First, it would be valuable to have the physicians evaluate how tests really affect the outcome for their patients and develop appropriate protocols. Malcolm Gladwell relates an excellent example in his book, Blink. The cardiology staff at Cook County Hospital was able to reduce tests while simultaneously improving patient outcomes.

[Gladwell, Malcolm (2005). Blink: The Power of Thinking Without Thinking. New York: Little, Brown.  ISBN 0-316-17232-4 (Especially the chapter on Cook County Hospital Cardiologists)]

Second, revise medical pricing so that it reflects reality—and that must include adequate margin to offset costs for necessary but expensive services. Emergency rooms are expensive to operate while an intensive care unit for patients suffering from burns is actually cost prohibitive. However, hospitals have an obligation to the community to provide necessary services—either directly or by affiliation—to the community. The community, in turn, must ensure the hospital is resourced to provide a wide range of services. If hospital prices reflected cost plus a reasonable margin to offset other costs, and everyone paid the same price—patient or insurance company, it might lead to more rational decisions—outcomes first, but economics as a consideration. If Grandpa—God love him—is a 96-year-old heavy smoker with high cholesterol and other morbidity factors who was hospitalized because of a stroke, a battery of tests that will not affect his quality of life or his longevity are not appropriate, and the insurer should not be expected to provide carte blanche payments. However, if the prices are realistic, the family may decide that they would be willing to pay for those additional procedures on their own.

Third, emphasize cooperation over competition. Is there any other business, other than hospitals, that would allow someone to work in their facility AND directly compete with it? Radiologists have their competing imaging centers, surgeons may have their private surgery centers, etc. Should specialty practitioners be entitled to benefit from the hospital’s patients and compete with the hospital for those same patients? It should be the practitioners’ choice—one or the other, but not both.

Two excellent resources for these issues are:

Brill, Steven (2015), America’s Bitter Pill: Money, Politics, Back-Room Deals, and the Fight to Fix Our Broken Healthcare System. New York. Random House. ISBN 978-0812996951

Rosenthal, Dr. Elisabeth (2017). An American Sickness, New York: Penguin Press. ISBN 9781594206757

If you want to fix American healthcare, pass this along to your friends, neighbors, doctor, etc. I’ll get a lot of hate mail, but we need to have the discussion.

More to follow.

Positions

No, not that.

There’s a great Monty Python bit in which the suitor is talking to his intended wife’s father. The abbreviated version would go something like this.

Graham Chapman: “Do you have a position?”

Michael Palin: (Snort) “I cleans public lavatories.”

Graham Chapman: “And is there a potential for promotion?”

Michael Palin: “Yeah–after five years they gives me a brush.”

We spend the first quarter of our life preparing to take on a position. The next two quarters of our lives, we define ourselves by our positions. Finally, we learn that our position is what we do, not who we are.

Jackson Browne (with, perhaps some help from his neighbor Don Henley) may have said it best in “Running on Empty”:

Gotta do what you can just to keep your love alive
Trying not to confuse it with what you do to survive

We are who we are and we do what we do–don’t confuse them.

 

Everybody panic! It might snow!

Buffalo, NY 2014 (Courtesy PBS)

Southeast Virginia’s TV meteorologists are in a full-blown tizzy because (gasp!) it looks like it’s going to snow. This is not necessarily bad, because TV meteorologists love to be in a tizzy over any weather event—but if you lived as boring a life as they do, wouldn’t you? The only other excoitement they get is standing outside in a storm on a live broadcast telling everyone else not to go outside.

Our neighboring states average the following annual snowfall:

West Virginia 62″

Delaware and Maryland 20.2″

North Carolina (due south of us) 7.6″

Virginia as a state averages 10.3″ per year, but the southeast (Norfolk, Virginia Beach, Hampton, Chesapeake, etc.) averages a paltry 5.8 inches, although eighty years ago, in January 1936, there was a record snowfall of 20 inches. Wow!

So, wish your television weatherman a happy blizzard, but leave quickly or risk having it all explained in great detail to you.

Undocumented Features

explo

Former Washing Machine Photo Daily Mail

Among software types there’s an old joke that programs never have bugs—merely undocumented features.

Hardware I catching up:

  • Airbags that spontaneously deploy and throw shrapnel at the car’s occupants,
  • Cars that adjust the engine to run one way during emission testing and another for regular driving,
  • Smartphones that burst into flames,
  • AND, my personal favorite—washing machines that explode

People today don’t realize how good they have it. When I was a kid, you had to do all these kinds of things the hard way—by hand. It was tough. If you wanted to blow up the washing machine, first you had to stuff the tub with a $#!+load of firecrackers with the fuses connected. There was always enough moisture left inside the washing machine so that half of them would get soggy. Still, once you lit the fuse, you had to run like hell to get out of the way. If the fuse fizzled out, you never knew how long to wait to go back and try to relight it without accidently blowing yourself up. We worked for results, and when we blew up a washing machine, we were proud!

Today, people just expect these things to happen all by themselves.

Complain, Complain, Complain!

I haven’t written much lately, or at least not much for the blog. (I have been working on a story, though. For some reason, writing fiction has become more satisfying than writing about reality).  I try, when I write, to focus on the silver lining rather than the cloud. Lately, this has become most difficult.

We’ve already discussed how the news media obsesses on all things negative—or meaningless (What’s wrong with Richard Simmons? Will Johnny Depp survive the breakup? Will Caitlin decide to become Bruce once again?). Every trend dies sooner or later, except, apparently for this one. I suppose it’s because they pick the stories that sell the most erectile dysfunction prescriptions, thereby financially benefiting the media, your physician, Big Pharma, venture capitalists, and investment firms.

I propose that we start anew. First, let’s hold a memorial service for journalism. It had a short and tragic life. The first American newspapers were all opinion pieces, but there was one brief shining moment—a century or so—when factual reporting became the gold standard. Many were thrilled at its demise.

My favorite magazines—National Geographic, Wired, and Smithsonian, and National Public Radio have begun to beat me over the head with more doom and gloom. I don’t care who just wrote a book to announce that they’ve come out as gay; I’m sorry that peasants hack down the rain forests because they need to plant food; I regret that there’s a controversy in reintroducing wild wolves into areas where cattle are raised; and I find it unfortunate that while developed countries used coal in the nineteenth century, we balk at twenty-first century countries using such antiquated (but economically viable) methods.  The difference is that rising sea levels today threaten ninety percent of the world’s population because they live near the coast.

In the 1960s we had a saying, “If you’re not part of the solution, you’re part of the problem.” Complaining, even if you’re a well-known television newsperson, accomplishes nothing. How do you plan to solve the problem? Like the ghost of Freddie Prinz the response seems to be, “Not my problem, man!”

So?

Solution to the Apple Kerfuffle

Syed Farook and Tasheen Malik killed fourteen people in San Bernadino, California. They apparently tried to dump their Apple iPhone, which actually belonged to his employer, the San Bernadino Health Department. Now, the FBI wants to see what’s in the phone and if it provides information to prevent future violent actions. The problem is that after ten attempts to enter the password, the phone erases its memory. The FBI wants Apple to unlock the phone’s memory and have a court order demanding to do so. Apple is refusing.

There are complex issues with the court order for Apple to unlock the iPhone used by the terrorists in California. Apple—and others—point out that if a “back door” is built into the software, somebody else will figure out how to crack into the phones. It is likely that these will be bad guys of one flavor or another. On the other hand, the phone may contain information that is critical to protect us from future attacks. Given that ISIS now has a quantity of Iridium 192, such an attack could be a dirty bomb, with hundreds or thousands of people exposed to radioactive material.

I propose a different approach.

If the solution is software, then it can be hacked. However, if a hardware hack is used, it would be more limited. It seems to me that Apple could physically remove the memory chip from the phone and make copies of its contents. Years ago there were programs that copied data bit-by-bit. This means that every 1 and 0 (the way that computers store all their data) would be copied exactly as they exist in the original.

This “master” could then be bit-by bit copied as many times as necessary; the FBI would have an infinite number of copies of the data to try to crack the password. After 10 failed attempts, the copy would erase, and the FBI could go to the next copy.

The advantage of using an approach that is hardware based means that it could be stipulated that breaking into a smartphone would require the legal physical possession of the phone and an appropriate court order to access the data. Since smartphones are radio devices and regulated by the Federal Communications Commission, this should be a federal judge so the Podunkville (population 15) judge couldn’t issue such an order.

It just might work.