Category Archives: Politics

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.

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.

 

July 4

When I was young, many of my peers’ grandfathers were veterans of World War I; most of the dads were veterans of World War II, and older brothers were serving in Japan, Korea and Germany. There were even a few individual who claimed to be Civil War veterans—supposedly drummer boys and buglers who had served quite young. Most of those were proven untrue, although there were widows of Civil War veterans; some veterans in their alter years married teenage brides. See Wikipedia’s story at https://en.wikipedia.org/wiki/Maudie_Hopkins. Now, all of the veterans of the wars before before World War II are gone, and those veterans, “the greatest generation” are fast disappearing.

July marks Independence Day, of course, but also the Battle of Gettysburg. I’ve already discussed how that one battle was pivotal in changing so many things and ultimately resulted in the United States becoming a world power—and I’m sure I shall again.

As a child I wanted to see the Gettysburg battlefield (I have, many times, but never enough). I wanted to see Halley’s Comet (a major disappointment; instead of the terrifying manifestation of the past, it was a fuzzy little dot you had to drive out to the country to see). And, after reading about the centennial celebrations of Independence Day, I wanted to experience the bicentennial.

John Adams and Thomas Jefferson died on the same day—the fiftieth anniversary of the Declaration of Independence, making it halfway to the centennial. Between the 150th anniversary and the 200th, the country was torn apart and patched back together.

The bicentennial for me was a combination of the enthusiasm and idealism of young adulthood, disappointment in the government for Vietnam and Watergate, yet I still had great hope for the future of the nation. I had no idea that such a future would include me.

I spent July 4, 1976 with my family at my sister’s place, which included a fair amount of land. We shot off enough fireworks to approximate the Confederate attack and Colonel Joshua Chamberlain’s defense of the Union’s west flank at Gettysburg. The smoke took hours to clear and the only casualty was one lawn chair that had suffered from the backflash of a series of roman candles.

I had my bicentennial.

Today I find it incredibly hard to believe that it was forty years ago. That since then I took an oath and served in two wars; that I served like my father and his father before him. That I have a son now serving.

My children and my grandchildren may get to see the tri-centennial. I hope it’s a wondrous celebration.

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!”

Lies, Damn Lies, and Statistics

The media try to help everyone avoid facts that might interfere with their willingness to accept, without question, the latest sound bite. Combine these efforts with an overall lack of critical thinking skills and a lack of understanding of mathematics among the population and it’s little wonder that we are in the position we are today. With the possible exception of big pharmaceutical companies, no one understands this better than politicians.

Take the debate swirling around firearms, for example. It is rife with anecdotal stories and inaccurate generalizations that lead you to the conclusion that murder most foul is rampant. However, according to a study by the Pew Research Center, gun deaths grew from 6.6 per 100,000 people in 1981 to a high of 7.0 per 100,000 in 1993, then dropped to 3.6 per 100,000 people in 2010. The Center for Disease Control and Prevention, on the other hand, reported 10.6 per 100,000 people in 2010, which then dropped to 3.5 per 100,000 people in 2013. Although each group gathers their data differently, the conclusion is the same—deaths due to firearms are lower than 35 years ago. Interestingly, they’re at about the same level as deaths due to automobile accidents.

Then there’s the brouhaha over photo identification in order to vote. The purpose, to prevent voter fraud seems reasonable, as does the statement that you need a photo ID card to get a library card, etc. However, is voter fraud really a problem, and if so, how much of one? Figures are difficult to find, but according to NBC in 2012, “A new nationwide analysis of 2,068 alleged election-fraud cases since 2000 shows that while fraud has occurred, the rate is infinitesimal, and in-person voter impersonation on Election Day, which prompted 37 state legislatures to enact or consider tough voter ID laws, is virtually non-existent.” That’s quite a crime wave—about 172 alleged cases throughout the country, every single year. I’m not certain what other crime occurs at a similar rate—attempts to steal the Statue of Liberty?

Then there’s the arguments between Pro-Choice and Pro-Life (arranged in alphabetical order). The emotional issue that always comes to the forefront is that it would be wrong to deny abortions to victims of rape or incest. Is that a significant group? Needless to say, accurate statistics are difficult to find, but the most frequent numbers buried in the fine print are either “one percent” or “less than two percent.”

I am not attempting to sway your opinion or your vote. I am merely demonstrating how so many issues are presented in a manner so as to elicit an emotional response rather than a rational one. As Jethro Tull sang, “I may make you feel, but I can’t make you think.”

Think back to school when your math teacher deducted points from a test because, even though you had the correct answer, you didn’t show your work. The media has mastered the technique of not showing its work (and some might claim it’s on purpose). In many cases the media loves to report a percent, but rarely do they share the denominator. The number upon which the statistics are based.

What is a 50 percent increase? If you start with 100,000 a 50 percent increase leads to 150,000. Of course, if you start with two, you can claim a fifty percent increase if you get to three.

As the political ad barrage season begins, ask yourself:

  • Is this a significant issue?
  • Is this an issue that can be resolved, or is it an emotional issue?
  • Are those making claims telling “the truth, the whole truth, and nothing but the truth?”

You may have to do a little research (Isn’t Google Wonderful?) to determine what the real facts are, but trust me—it’s worth it.