Category Archives: Media

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.

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.

Inspiration from the Movies

Indiana Jones and the Last Crusade

Indiana Jones and the Last Crusade

I love movies, although I no longer have the time to devote to watching as many of them as I’d like. In a few years, when I retire, I hope to correct that problem.

Movies aim to elicit feelings, not thoughts, but sometimes feelings actually lead to critical thoughts. Take, for example, the Indiana Jones movies; while “The Search for the Lost Ark” was wonderful, the “Last Crusade” was important. It touched on some lessons that we don’t teach in schools, but are critical nevertheless.

Indian Jones, a fictional archeologist from the time when archaeologists were more “pot hunters” than scientists, seeks the Holy Grail—the cup Jesus drank from at His last meal. To reach the grail, he must pass three challenges:

  • The Breath of God – “Only the penitent man will pass.”
  • The Word of God – “Only in the footsteps of God will he proceed.”
  • The Path of God – “Only in the leap from the lion’s head will he prove his worth.”

    (http://indianajones.wikia.com/wiki/Temple_of_the_Sun)

What can we learn?

“Only the penitent man will pass.”—None of us are perfect, and we must be sorry for how we’ve hurt one another.

“Only in the footsteps of God will he proceed.”—God has given us direction through so many means, all of which come down to, “Love God above all things, and love your neighbor as yourself.”

“Only in the leap from the lion’s head will he prove his worth.”—It takes faith to live, grow, and do good in this world. Logic alone is not enough; logic applies only to this world, while faith touches the next.

God, in his infinite wisdom, touches us through scripture, religious communities, and even the movies. But then, since He is God, why wouldn’t He?

Television, But First, This Word . . .

I confess that I don’t watch a lot of television, mainly because of lack of time. I do watch the local news as I’m getting dressed in the morning, which is mainly limited to weather, traffic, and a smattering of journalism. There are a few prime-time shows I like, but normally we watch those through the DVR.
I understand that commercial advertisements pay the bills for television stations, but sometimes it seems a bit overdone. I have never timed it, but it seems like the local morning news is about 50 percent commercials. There are pitches for replacement windows, new and used cars, lawyers, furniture stores, pawn shops, and even churches. During elections they add a ton of political attack ads. Alas, while I’m trying to wake up in the morning, I’m not particularly persuaded to seek anything from those advertisements.
Our cable company overrides customers’ ability to record the most popular prime-time programs on the in-house DVR, but instead shifts them to their “On Demand” service. The difference is that with their recording one can no longer fast forward through the commercials; if you pause the program for too long, it disengages and you have to restart the program from the very beginning.
The commercials on the time-shifted programs include erectile dysfunction drugs, other programs from the same network, erectile dysfunction drugs, public service announcements, erectile dysfunction drugs, an occasional product, and, of course, erectile dysfunction drugs. I suspect that these are not exactly the same as during the original broadcast, but that’s just a guess.
It’s no wonder I prefer movies and books.

Elites

While we often talk about elites, we tend not to use that term. Elites are the people in any society who enjoy special privileges.

For a long time, elites were entitled to such status as a birthright, the most obvious example being royalty. If your father was King, it must be God’s will, and therefore the son must be qualified as well. Personally I don’t think God gets involved in politics, but you never know.

John Adams predicted that even though our constitution prohibited titles of royalty there would still be an elite class. He figured that those with educations would prosper, ensuring that their offspring would be afforded education and any wealth that the family had amassed, although in many cases the younger elites ended up with an education and the family debt. Nevertheless, they enjoyed the status.

The American dream is that we’re a meritocracy—anyone can achieve through ability and hard work, and sometimes this works. In fact, there have been periods in our history, such as the 1950s, when this was common, Nevertheless, it is not guaranteed.

Today, many of the elites once again obtain their status by birthright. There are many young men and women as, if not more talented, than the children of Tom Hanks, Will Smith, or the Barrymore family. However, it is the children of the elites who seem to land the acting roles. Is Eddie Van Halen’s son better than the band’s original bassist? Cheap Trick sold many albums with Bun E. Carlos as their drummer, but Rick Nielsen—the guitarist now has his son filling that spot.  Julian Lennon didn’t have to work his way up from playing wedding and bar mitzvah gigs. How many Fords have been senior executives at their namesake auto company?

Do we as a society get our best value from this practice?

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?

You Can Use My Bathroom When You Pry My Cold, Dead Fingers from the Toilet Paper!

I love to keep my tempests in teapots—it keeps the rhetoric hot, even if there’s no real substance. For example, the brouhaha regarding who gets to use which bathroom. Last report that I heard on NPR was that in the state of North Carolina, where the sexes are separate, but equal, the number of complaints regarding use of the inappropriate bathroom was zero. Nada. Zilch.

I suppose that between NPR and myself, our comments will encourage someone somewhere to complain. So be it.

Those who served in Iraq or Afghanistan either had various choices for conducting urination and defecation. Some had the pleasure (?) of field latrines, others the ubiquitous porta-potties, or, around places like Al Faw Palace near Baghdad, the existing bathrooms were declared co-ed. The stalls were first-come, first-served (oddly, there was no competition for the urinals). That’s what was there, so that’s what the Americans used. (Of course there were the Arab toilets, a hole in the ground with footprints marked on the surrounding concrete, and a short garden hose. I’ve used them–works for them, not for me.)

The reason that it doesn’t matter was best described by that Great American Canadian, Bill Murray in Stripes, when he said, “We’re all mutts! See—his nose is cold!” And it’s true, we are mutts, and that’s what makes Americans, well, Americans.

Don’t believe me? The following is a true story:

A senior Marine officer was at one of the detention sites shortly after the fall of Iraq in order to make sure that the prisoners were being properly treated (for every Abu Graib there were dozens of facilities that were run in accordance with international law and reasonable civility). An Iraqi general kept frantically motioning that he wanted to talk, and although the Marine officer was not really interested in getting into a debate with the Iraqi general, he realized it was his duty, and courtesy demanded that he acknowledge the general. The Iraqi spoke English with a heavy accent, so it took a while before the Marine understood what he was being asked.

“Why do you conquer us with this confederate army?” the Iraqi general wanted to know. He pointed to the enlisted Marines who were with the officer. “This man,” the Iraqi continued, “is obviously from Asia. That one from Africa, and the other probably from somewhere in Central or South America! Why did you recruit these foreigners to invade us?”

The officer looked around; until that moment, he had never given a thought to their different ethnic backgrounds; he had always seen these people as fellow Marines.

We are not a nation bound by common ancestors; we are a nation bound by an idea. Every one of those Marines had sworn an oath to that idea—the United States Constitution.

We Americans are all different from one another. My recommendations to survive this great challenge are, when using a bathroom:

  • Don’t trash the restroom (which for teenagers will be a HUGE challenge)
  • Be polite to whoever else is in, entering, or leaving the restroom

Oh, and this may shock you, but everybody without four legs or wings, who visits my home, regardless of ANYTHING, all share the same bathrooms.