Category Archives: Healthcare

Football In the Future

Football Hall of Fame Re-opens

Newly remodeled Football Hall of Remembrance opens to celebrate Traumatic Brain Injury.

SATIRE AFFILIATED PRESS
CANTON, OHIO 11 September 2035

Although American style football has been banned, the Football Hall of Remembrance—formerly the Football Hall of Fame—is still a popular tourist attraction. It’s remodeling was recently completed and the familiar football roof is now surmounted by an artist’s conception of traumatic brain injury. Over the front door, the entryway features a bronze relief of a player being carted off the field after, as they used to say, “Having his bell rung.”

While the exhibits still include trophies, helmets, jerseys, and other game paraphernalia, it’s the preserved brain tissue and MRI scans that are today’s favorite. Visitors can view the pathology, then try to guess to which famous player the brain once belonged. Pressing a touch screen, the player’s name, teams, scores, and number of concussions is displayed. Original plans included videos of interviews with former players, but many could no longer communicate, being content to babble incoherently, or stop mid-sentence with, “What did you just ask me?”

Taking a page from big tobacco’s playbook, the industry insisted for years that football was not dangerous; eventually there were too many injuries at the high school, university, and professional levels to ignore. Professional teams found that medical insurance costs exceeded revenues—even if the revenue from sale of team products like hats and jerseys are included. With the profits gone, most owners took their investments elsewhere. Unfortunately, this left many cities with substantial debt for stadiums they built. Many are crumbling and have been condemned because of the degree of deterioration; there’s reason to repair them and no money to tear them down. Universities initially expected a huge financial crisis, but found that the sport had actually not been a money maker, in terms of real cash, but a huge annual loss. Without football many universities were able to improve facilities and pay teachers better.

Football, is gone, but not forgotten—except by those who played the game and had their bells rung too many times.

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.

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.

Mayonnaise

As promised, in order to be completely politically correct, this blog is devoted to mayonnaise. Perhaps devoted is too strong a word, but it will be about mayonnaise—I don’t want anyone thinking I have some kind of mayonnaise fetish.

Wikipedia says that mayonnaise is, “a thick, creamy dressing often used as a condiment. It is a stable emulsion of oil, egg yolk, and either vinegar or lemon juice, with many options for embellishment with other herbs and spices.”

I say that mayonnaise is politically correct, non-controversial and slightly bland.

Many of us grew up being told that the most dangerous thing at a picnic was not the poison ivy, the fire ants, or even hungry bears. We were warned to avoid any potato salad that had been out of the refrigerator for more than ten seconds because it would spoil, cause food poisoning,  and we’d die a slow, painful death. Some years later I heard on the radio that because mayonnaise contains vinegar and/or lemon juice—both acting as preservatives—this was unlikely. Of course the guy on the radio might have actually intended to be a mass murderer and slaughter thousands of gullible listeners,wielding spoiled potato salad like a deadly weapon.

There’s phony mayo, labeled either “Salad Dressing” or “Phony Mayo.” Considering that a dab gets added to a sandwich filled with several kinds of meat, cheese, lettuce, tomato, pickles, and jalapenos, I’m sure most people couldn’t tell which dab had been added to  the sandwich they were eating.

Spices are often added because mayonnaise is slightly bland. You must be careful, though since adding things to mayonnaise, changes it. Add mustard to mayo and you have remoulade. Add chopped cooked potatoes, eggs and celery and you have deadly potato salad.

I hope you have enjoyed today’s politically correct, non-controversial, and slightly bland blog. Please do not leave this blog outside in the summer sun as it may spoil and kill you.

Medical Abbreviation$

When I sleep, I use a CPAP, which is an abbreviation for, “I’m buying some doctor a Jaguar to drive.” There are several sound medical reasons for the CPAP:

  • First, I suffer, from chronic healthcare insurance. As long as I have insurance that pays for treatment, the medical industry will find things wrong with me.
  • Second, I have sleep apnea. This mainly means that when I sleep, I snore. Technically it means that I stop breathing while snoring, but I’ve never noticed this. Perhaps it’s because I’m always asleep when this happens.
  • Third, I’m gullible. I actually believe it when someone says, “Here, wear this facemask every night and you’ll sleep better, lose weight, and have a better sex life.” (The preceding is actually true; those were the words of the sleep specialist).

I realize I’m older, and to paraphrase Indiana Jones, “It’s not just the age, it’s the mileage,” but it’s amazing how every trip to the doctor leads to a battery of expensive tests, followed by an expensive prescription. Once, when the doctor couldn’t find anything specific wrong, he wrote me a prescription for a drug specifically formulated to treat a patient with a lack of symptoms.

And so it goes as we get older, yet there’s nothing we want more than to get even more olderer.

We Are Oh, So Smart!

Blood_letting.1

We twenty-first century humans are the pinnacle of humanity in so many ways. We can kill one another with great efficiency AND effectiveness. We can blather to the entire world about absolutely nothing, thanks to smart phones and social media (excuse me while I shoot a selfie).

No one in history was as great, and wonderful (and, might I add, humble) as us. We are the undisputed technological winners.

Well, mostly.

There is that thing about Damascus Steel that the ancients could do with sword blades that we have never duplicated. Imagine what amazing Ginsu knives could be made of that! Or weapons for Seals and Delta Force! Or surgical scalpels and medical implants!

We’re proud about our computers and claim them as our own, but then there’s that mechanical computer from the first century found in a shipwreck by Greek sponge divers. Some say that if it had not been lost, civilization would have advanced so that space exploration would have begun centuries earlier.

And now we find that the bacteria that can whup our best antibiotics (with one pseudopod tied behind its back), Methicillin-resistant Staphylococcus aureus (MRSA) can be controlled by a concoction from the tenth century. An eye salve, found in Bald’s Leechbook, made from fermented, garlic, cow bile, and wine appears to be effective against the disease in several trials. “Leechbook” because the barabarian healers still believed in bloodletting—yet the barbarians got this one figured out better than we did. (Oddly, my insurance provider doesn’t have it in their pharmaceutical formulary, so if I need it, I have to pay for it out of pocket.)

If we truly are smart, we’ll honor those who came before, and figured out some things that demand our respect.

Why My Mechanic Is More Trusted Than My Doctor

I swear that this is not associated with yesterday’s Jobsxtaposition topic.

I love science. I love thinking, questioning and learning. I love Edison’s I didn’t fail, I found a thousand ways NOT to make a lightbulb. Think. Hypothesize. Experiment. Compare results to expectations. Think some more. Question why things turned out the way they did.

I love logic. I love the steps to prove that something is true; I’m challenged by, but accept that you cannot prove something is false.

However, the practice of science today is be very different than my expectations of science. Today, at least according to the media and the politicians, we rely on consensus rather than experimentation, opr God forbid, fact.

How did this happen? Maybe it started with global warming. If we cannot prove that man did not cause it (because you cannot prove a negative) therefore, it is a manmade problem. Why? Because we have a consensus!

There was once another proud science – medicine. While I was doing some research I came across an interesting issue; doctors are expected to treat patients according to universal standards. If the majority of doctors prescribes medicine A or surgery B, and your doctor prescribes therapy C he or she can find themselves in big trouble if they don’t follow the consensus. They could be censured or lose their license. A handful of states have written laws to protect doctors who dare to think, but in most states the medical profession has the clout to keep the state legislature in line.

So, after four years of college; medical school; internship/residency; and several years of fellowship, doctors are expected not to question or think. They are expected to follow the consensus; order the consensus driven tests, prescribe the consensus driven treatment and not vary from the consensus.

Hmm.

My doctor is a wonderful guy. He orders various tests and based on the outcome of the tests he prescribes certain treatments and medication. There are guidelines he is expected to follow. If he varies from the universally accepted (i.e. consensus) he faces consequences.

My auto mechanic is a wonderful guy. He connects my car to the diagnostic computer and based on what the computer says, he makes certain repairs. There is a book that tells him what to do and what to charge. He’s a smart guy, but doesn’t have the education of my doctor.

The difference is, that if my mechanic wants to try something out of the ordinary, he can, and does, and it often fixes the problem, thank you.