Category Archives: Government

It’s Good to Be the Tsar!

putin

Vladimir Putin, according to reports, is wealthier than the next two richest people combined with a net worth of $200 billion. Pretty good for someone who grew up as Communist with enough commitment to work for the KGB.

His career with the KGB was unremarkable (his highest rank was lieutenant colonel), but once he got into politics, he found his niche. Trained as a lawyer, he adopted the Don Corleone business model (“One lawyer with a briefcase can steal more money than 100 men with guns.”–The Godfather). When the Soviet Union fell, various Russians began to acquire wealth. Putin apparently made many of them an offer they couldn’t refuse.

It might be good to keep that in mind before considering doing business with Putin.

Fixing Healthcare – Part Three

Physician’s Assistants (PAs) and Advanced Registered Nurse  (ARNPs) are helping lower costs and increase access. While some nurse practitioners, can operate relatively independently; other nurse practitioners and most physicians’ assistants, cannot. Why?

Physicians are adamant that they maintain a high degree of control over these and other healthcare workers. This is a throwback to the nineteenth century—which is kind of interesting in a weird sort of way. The story, and I cannot vouch for its accuracy, although all my research seems to support it, is that the country was besotted with traveling medicine shows hawking patent medicines (You’ve seen it in the movies—“One for a man, two for a horse”). The physician industry supposedly promised to get things under control if they were put in charge of medical practitioners, i.e., physicians and surgeons (MD). It, at best, minimized, if not blackballed, osteopathic physicians (DO), chiropractors (DC) and chiropodists, now known as podiatrists (DPM).

A physician, at the time, could authorize any hireling under his license to perform any duty under the concept that the doctor was “the captain of the ship” and was responsible for everything. Therefore, he had authority to authorize any employee to do anything—hopefully, but not necessarily, after some training.

Today, many non-physician healthcare workers are licensed in their own right; in most states this includes nurses (of all levels), therapists (of all varieties), and technologists (ditto). These people are trained and possess technical skills that physicians do not. Generally speaking, only television doctors leave their practice in order to operating high technology devices. It’s good theater but bad economics.

Many of the other healthcare careers such as nurse practitioners, physicians’ assistants, etc., have made significant advances Unfortunately, old attitudes die hard, and there are too many physicians who try to maintain an inordinate control over everything, including these other professionals. Nurse anesthetists and physicians’ assistance must be “supervised” by a physician, although such supervision does not require actual observation or even the presence of the supervising physician.

Efforts to keep others under control have led to some bizarre arrangements. In radiology, for example I’m told that the technologists are now required to periodically retake the examination that initially proved their competence even though there has been continuing education requirements for 40 years. If true, I believe this is a unique requirement, but a warning to all others. Of all the physicians’ assistants, only those specializing in radiology are not permitted to interpret x-ray or other diagnostic images.

Why?

Some blame the American Medical Association, a very powerful organization with effective lobbyists. However, it apparently speaks for a self-selected group of physicians. Out of 923,308 practicing physicians, the most recent numbers available indicates that only 228,000 belonged to the AMA. If you don’t round, that’s just less than 25 percent.

Nobel Laureate Milton Friedman and his wife, who wrote the book Free to Choose, asserted that the AMA functions more like a guild with the goal of increasing physicians’ wages and fees by limiting both the supply of physicians and the competition from non-physician groups.

This is yet another issue that must be addressed if we are truly interested in fixing healthcare.

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.

The Decision and the Declaration

Today, on July 4th, we celebrate the Independence Day, when the Declaration of Independence was approved by the Continental Congress in 1776.

However, history is more interesting than just the event and the date.

On June 7, 1776, the senior Virginia member of Congress, Richard Henry Lee introduced a resolution stating:

Resolved, That these United Colonies are, and of right ought to be, free and independent States, that they are absolved from all allegiance to the British Crown, and that all political connection between them and the State of Great Britain is, and ought to be, totally dissolved.”

Congress adopted the Virginia motion on July 2, 1776, thereby refuting our status as a colony; this is why John Adams believed that we would celebrate our independence on July second, the date of the decision.

The Declaration of Independence was approved two days later, on July 4, 1776.

While the Declaration of Independence is a masterpiece, and I recommend that everyone read it today, it was not the decision, but merely the explanation to the world as to why the decision had been made. Although we have seen many portrayals of all the Founding Fathers assembled together in Independence Hall to sign the document on the fourth of July, most, but not all, signed on August second; one signer, who was not a member of the congress until later in the year, signed in November.

As is often the case, history is more complex, and far more interesting than the snapshot presented in civics class.

* Thanks, once again to Wikipedia. If you use it, kick in a donation—even a dollar helps.

 

Memorial Day

Graves at Arlington on Memorial Day.JPG

 

I don’t celebrate Memorial Day.

I do cook out and consider it to be the summer season and I enjoy the three-day weekend, but celebration brings to mind happier events. I do not wish people a “Happy Memorial Day.” Instead I observe Memorial Day as a day of remembrance, when we honor those who gave, in Abraham Lincoln’s words, “The last full measure.”

There arguments as to how it started, but even though decorating the graves of fallen warriors is an ancient tradition, it took root in America after the Civil War. The Civil War was devastating not only in terms of bullets, but disease that swept through the armies before, during, and after the battles.

The North credits the Grand Army of the Republic—the veterans of the Union military—for starting it in 1868. They called it “Decoration Day” because of the flowers on the graves; its first observance was on May 30th because that date did not coincide with any significant Civil War battle.

There are others (including the US National Park Service) who claim that it began in Columbus, Georgia in 1866. There it was called “Memorial Day,” although after the North co-opted the idea (and the title), they called it “Confederate Memorial Day.” There was not a specific date throughout the South.

There is one other theory.  In South Carolina, Union soldiers were held in a makeshift prisoner of war camp that was actually a race course.  At least 257 Union soldiers who died in the camp were buried in unmarked graves. In 1865 freedmen—African-Americans who had been slaves—cleaned and landscaped the site and built an enclosure with an arch that said, “Martyrs of the Race Course.”

Regardless of its history, we now celebrate it on the last Monday in May with lots of sales at every retail store, and not enough thought of those who died in while in the service.

For clarity’s sake:

Memorial Day—the last Monday in May—honors service members who died while serving.

Veterans’ Day—November 11th commemorating the Armistice of World War I, which occurred at the 11th hour on the 11th day of the 11th month—honors all who served in uniform.

Armed Forces Day—The third Saturday in May—honors those currently serving.

 

 

The Candidates (Revised)

After being politically correct for the past few weeks (some by omission), here we go.

The Clintons at the Trumps’ 2005 Wedding

 

Now that the presumptive candidates (and, they’re both quite presumptuous, thank you [rim shot—bada-bing]) are in place, the world is beginning to react.

Great Britain: “I say, old chap, do you miss King George the Third yet?”

Vladimir Putin (AKA Russia): “Of course this is all according to my plan, but I assure you that no Russian military troops were involved!”

Mexico: “Here’s our counter offer:

  1. “We are willing to pay to build a wall, but we propose a different—but better—location. The wall would be more beneficial to the citizens of both countries if it were constructed about fifty meters outside the right-hand lane of I-495, thereby encircling Washington, DC. This would help maintain control of politicians’ entry into the United States of America mainland.
  2. “The wall will be funded by charging a toll for travel through the numerous tunnels that already exist under the border between our two countries. Since the tunnels are well-engineered, structurally sound, well lit, and either paved or equipped with rail service, it should be easy to add electronic toll transponders. Of course, after the election, there may be many US citizens who will utilize the tunnels to head south in a search for a more placid place to call home, and they would be responsible for paying the toll as well. Please ensure that the EZ-Pass transponder system deposits the fees into Los Estados Unidos de Mexico National Bank.
  3. “Incidentally, we revised our immigration laws in 2011. If you’d like a copy, you can easily get it online.”

North Korea: “As a gesture of confidence in our future relations, we would be most willing to host any of your e-mail servers. I assure you that the DPRK has many well-trained computer specialists, and we would treat your computer as we would treat one of our own.”

Canada: “Hey! No way, hoser! Take off, ay? There are reasons that we prefer to be neighbors rather than family. We like our prime minister just fine, thank you, since he’s cultured and refined. Besides, our beer is much better than yours!”