Category Archives: 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.

 

Murphy’s Law and Aging

Bob came into work the other morning, looking more unhappy than I’d ever seen him before; naturally I asked him why he looked so glum.

“I’ve worked hard all my life,” he began. “You know that as well as anyone. We cut corners and pinched pennies. We managed to raise three kids, giving them whatever support we believed to be important. They all graduated from college and their careers are all off to a good start—a real good start, if I do say so myself.

“For years, it was Burger-Helper, buying used cars that we then kept for ten or twelve years, and foregoing vacations. Neither my wife nor I minded; it was for the family. But after the kids had grown, we sold the house and moved into a brand new home. We designed it ourselves; it was a smaller place ideally suited to a couple. It had a beautiful master bedroom suite. The kitchen was equipped with professional level appliances—larger cooking area, smaller eating area.

“We enjoy cooking gourmet meals together—it gives us a great chance to just chat, so after slicing, dicing, and sautéing together, we’d sit together in the smaller dining area which seemed, well, romantic. Outdoor cooking is just as fantastic. The patio is built around a grilling system complete with mini-refrigerator, wine cooler, and a sink with hot and cold running water. All the things we had given up for so many years, we could now plan on enjoying: a beautifully aged, well-marbled steak accompanied by a lobster, gourmet cheese, a stuffed baked potato, freshly home-baked bread, fine wine, exquisite desserts and for me, with the political climate changing, perhaps even an after dinner Cuban cigar.”

“That all sounds wonderful,” I offered, “so why so sad?”

Bob took a deep breath. “I went in for a ‘routine’ medical visit—the ones I had often tended to skip for financial reasons in the past. The doctor ran all the fancy lab work and such, and then called asked me to stop back in for the results. That worried me of course. Fortunately it wasn’t to tell me I had cancer or whatever.”

“Then what was it?” I asked. At this, Bob sobbed.

“He told me all the years of eating cheap food had taken its toll. Forget the steak and shellfish—too high in cholesterol. The French advise ‘either cheese or dessert.’ My doctor says ‘neither cheese nor dessert.’ Bread and potatoes have too many carbohydrates, and I don’t have to tell you about the lecture I received about starting to smoke at my age.”

“Wow!” I replied. “You must have been devastated!”

“That’s not the worst of it,” Bob replied. “He said, ‘Guys your age all think they should be able to enjoy wine, women, and song. Go easy on the wine. You have a wonderful wife, so it’s woman
not
women, and, by the way, if you want to keep her—since I’ve heard you sing—I’d suggest you limit your singing to church.”

CDC and Ebola

Spanish flu treatment center Smithsonianmag.com

Spanish flu treatment center
Smithsonianmag.com

My congressman ran a poll asking his constituents if they were confident in the Center for Disease Control’s (CDC’s) ability to combat Ebola. He’s probably sorry he asked, because this is how I responded. Obviously these are my own opinions (aren’t they always?), although I did try to check basic facts (number of dead in World War I, etc.)

I spent 30 years in the healthcare industry, starting off in a technical clinical discipline, and later, after completing my graduate degree I moved into management and was a Fellow in the American College of Healthcare Administrators. My current position includes support for emergency management.

CDC is very good at doing certain things, but their best work has involved basic research, which doesn’t mean “simple” but getting to the root issues behind a scientific question. Basic research is often the most result oriented because instead of jumping to a search for the solution, it instead focuses on learning about the problem without preconceived notions. The classic example was when Dr. Fleming noticed that something was affecting the other bacteria in his experiment. By studying this “something” he discovered penicillin.

It appears that in recent that the attention of the leadership of the CDC has been drawn away from basic scientific research and become more focused on political issues, which well may have impacted their effectiveness. For example, there are reliable reports that CDC has spent significant effort to shut down doctors who believe in treating chronic Lyme disease. Some physicians believe that the organisms that causes Lyme disease, and an associated disease, babesiosis can become dormant in a patient, but when triggered by trauma, or other events, the symptoms become active again. Although not scientifically proven, patients have reported improvement when treated with a regimen of certain antibiotics and anti-parasitic drugs.

The CDC has not proven these conditions do not exist, which is understandable given that it is impossible to prove a negative. However, they have taken this issue on as a crusade and allegedly gone so far as to classify this as a Homeland Security issue in order to justify the use of legal authorities and law enforcement techniques.

Unfortunately, they have not been quite as enthusiastic at adhering to basic, proven infection control techniques they haven’t exerted the same amount of effort to adhere to basic protocols resulting in the exposure of CDC personnel to anthrax and the loss of at least one container of viable small pox. Incidentally, small pox was the first chemical weapon when the blankets of small pox victims were given to Native Americans, thereby intentionally introducing the disease to the indigenous population of North America.

I’ll give the CDC the benefit of the doubt. I think they can handle this IF the politically appointed and wanna-be-police types get out of the way. Should we cut off contact with western Africa and deprive them of essential expertise, medicine and equipment? I think not. While it may be politically unpopular, until effective treatments or vaccines are perfected, quarantine may be the most logical step. The health professionals actively working with Ebola patients at the handful of designated hospitals are the best trained and equipped. However, mistakes are made, equipment fails, and while the doctors, nurses, therapists and technologists may follow the protocols correctly, is it possible for a housekeeper or a maintenance person to become infected? I think so.

It may be wise to quarantine people who have been exposed to Ebola. The Ebola hospital staffs may just have to live and work within the confines of the facility for the duration. It’s an inconvenience but our military men and women have been living with such inconveniences for the past eleven years, all the while being shot at, rocketed, mortared and the target of suicide bombers and IEDs.

If the USNS Comfort and USNS Mercy – the Navy’s 1200 bed hospital ships are not being deployed elsewhere, they could provide medical care as well as quarantine. Those exposed and being monitored would not have to live in military austerity, but instead could be housed in nicer accommodations to make the experience less painful; a hotel leased by the government, or perhaps a cruise ship. Nice accommodations, but safely out of circulation until everyone is sure that the individual is not infected

If everyone exposed to Ebola were quarantined for 28 days, it just might prove to be significantly cheaper to pay for lost wages and accommodations for these people than to let the disease spread. If the CDC puts the science and safety first, they’ll succeed. If the politics and power struggles take precedence, stand by. Those who do not study history are doomed to repeat it. The “Spanish” flu of 1918 is estimated to have killed between 50 million and 100 million; by comparison, the total death toll of the Great War (World War I)— all military and civilians—is estimated at 43 million.

Bottom line—let the scientists do their job.