Sunday, December 4, 2016

Why We Can't Control Medical Costs.

Most of us are skeptical that insurance companies are devoted to our health.  Answer the following question.  Do you think your insurance company is more interested in your health or in controlling costs?  Pretty tough question, huh?

There is a tension between medical quality and medical costs.  If we had a system that offered perfect quality, it would be unaffordable.  If we imposed rigid cost controls, then medical quality would be compromised.  Where do we draw the line?

 It is clear to most of us that the medical industrial complex is riddled with waste.  Keep in mind that one man’s medical waste is another man’s income.  For example, physicians define waste as excessive charges by hospitals.  Government officials define waste as excessively high drug prices.  Patients define waste as high co-pays and deductibles.  Drug companies define waste as outrageous legal expenses to get drugs to market and to defend against frivolous lawsuits.  Primary care doctors define waste as unreasonably high reimbursement that medical specialists receive.  Keep in mind that most folks don’t feel they are overpaid, but are quick to point to others whom they accuse of being overcompensated.  For example, when a politician floats a proposal to tax the rich, we hope that the definition of rich is anyone richer than we are.

Steak is cheap when someone else is paying for it.

Get the idea?  In summary, medical waste is easily defined.  It is money that someone else earns. 

This is why excising medical waste from the health care system is so difficult.  Who would you trust to decide which waste should be wasted?  The government?  Physicians?  Pharmaceutical companies?  I don’t have an easy answer here.   Part of the solution, in my view, is when patients have a little more skin in the game.  Here’s how this works.

A physician advises an MRI of the back on two different patients.  Patient A has full coverage for the study and would face no out-of-pocket costs.  Patient B has a $5,000 deductible and would have to write the radiologist a big check.

Patient A: “Thank you, doctor. My back has been hurting for over a week.  I’d like to get it done as soon as possible.”

Patient B: “$940!  Can I try those exercises you recommended instead?”

It’s always easier to spend someone else’s money.  Do you find that you order differently in a restaurant when it’s on someone else’s dime?

Sunday, November 27, 2016

Discussions at Thanksgiving Tables in 2016

While folks across the country were gathered around their holiday tables, I suspect that conversations were not focused on the First Thanksgiving when the Pilgrims broke bread with the Wampanoag native Americans over a 3 day feast in 1621.  There was no pumpkin pie or cranberry sauce served then, and it was more likely that venison was on the table than turkey.  Sometimes, myths are more fun than facts.


The First Thanksgiving at Plymouth

I surmise that the many of our Thanksgiving dinners were sites of spirited discussions regarding a recent political earthquake that convulsed this country.  Indeed, over the past 3 weeks, I have departed from this blog’s medical commentary, to offer some thoughts on what occurred and why.

The nation is sorely divided, but I sense that there will be healing, depending upon everyone’s ability and willingness to listen deeply and absorb the views of reasonable folks whose opinions differs from ours.  Reasonable people are rarely all right or all wrong. 

The campaigns were ugly and many of us abandoned the better angels of our nature.  While candidates must be held to account for what they said and did, I expect that the incoming administration will operate within normative restraints.  The republic is like an ocean liner whose course is not easily derailed. 

The American experiment is succeeding.  For over two centuries, we have witnessed a peaceful transfer of power in accordance with the wishes of the governed.  Not a shot was fired. The current president and his administration stepped up to assist the president-elect and his team to effect a smooth transition.  The fact that the president so vehemently opposed the president-elect, and yet pledges to help him now, only reinforces the majesty of our democratic republic. 

Can we all be thankful for this?





Sunday, November 20, 2016

Breaking News! Trump Chooses Conservative Advisors!

Let the whining begin!  Donald Trump, the president-elect, has chosen Mike Pompeo, Michael Flynn and Jeff Sessions to serve as CIA director, National Security Advisor and Attorney General respectively.  Here’s the shocker.  They are all conservative! 

Let me offer some guidance to the demoralized and deflated liberal, I mean ‘progressive’, political left.  When the nation elects a president who resides to the right of the political center (leaving aside that where Trump truly resides is an arguable question), he is going to choose personnel who share his philosophy.  Trump ran hard on immigration, trade, anti-terrorism policy and the Supreme Court.  Now elected, he should be expected to assemble a team that will further the objectives that he campaigned on.  Isn’t this what we expect when a candidate gets elected?

I think that Trump’s appointments mentioned above – all of whom are qualified – cause the left to hyperventilate in an effort to distract their base from their horrendous and systemic electoral defeats they suffered all across the country.   Keep in mind, cabinet positions are not lifetime appointments and all reasonable people agree that a president should be afforded great latitude in choosing his team members.  Americans today can expect very different priorities and philosophies regarding national security, immigration policy, law enforcement and foreign affairs.  This is the natural course of events  when the White House changes hands.


Intel Pros will be allowed to say, Islamic terrorists.

Isn’t this exactly what occurred when President Obama took office in 2008?  Elections matter, as the president himself has often stated.  Were we shocked that his choices for Attorney General of Eric Holder and Loretta Lynch focused on civil rights and were not regarded as champions of the law enforcement community?  Obamacare passed without a single Republican vote.  His Supreme Court choices of Elena Kagan and Sonia Sotomayor were not quite the judicial soul mates of the late Antonin Scalia.   Just today I read that the Obama administration will block new drilling in the Arctic Ocean, an example of several of the president’s actions that have tilted toward environmentalists’ concerns.  Liberal presidents tend to govern liberally.

Trump was criticized, properly in my view, for stating that he would only nominate pro-life individuals to the Supreme Court.  (I’m against judicial litmus tests for specific actions or policies.)  Before you criticize him over this litmus test, remember, that Hillary Clinton commited the same offense when she declared she wanted her nominees to overturn the Supreme Court’s Citizen United decision?  Were you critical of her also?  Trust me, when President Trump offers his nominations for the high court, and he may have more than one opening to fill, we should not be shocked that they will view the judicial world through a conservative lens. 

Instead of carping about a new president’s personnel choices just to offer balm to your political base, why not contemplate the hard lessons that caused your party to be thoroughly trounced and repudiated?  Then, bring your own ideas and vision into the marketplace of ideas and compete for votes.  Then, if your side prevails, you can choose your own team to carry out your mission. 


Sunday, November 13, 2016

Trumped!

Many folks talked about the possibility of an October surprise prior to our recent presidential election.  Rumors swirled of an FBI bombshell, more WikiLeaks or a Russian hack attack.  The predictors were off by a month.  We received instead a November surprise that many view as apocalyptic.  The nation was shocked, as were the candidates, despite Trump’s minions’ confident public exhortations of victory.  How did the press and the punditocracy get it all wrong?   Even days prior to the election, many pollsters were placing Clinton’s chances of victory in the 75-90% range. 


An Unexpected Guest

We are beginning to understand how a man who has never held elective office, who by all accounts is a boorish and vulgar narcissist, could vanquish 17 Republican adversaries to gain the nomination and then handily trounce the Clinton political machine on November 8th.   The brash outsider prevailed over the consummate insider.  We are beginning to understand why his unending stream of deeply offensive rhetoric and behavior, which would have doomed an ordinary candidate, seemed only to burnish his street cred and approval ratings.  
The answer is not pretty.

Both parties have been arrogant, hypocritical and corrupt as they ignored or chose not to be attentive to so many of their constituents.  Look at politicians' approval ratings in either party.  I think the electorate reached a tipping point.  Can you believe that Bernie Sanders, a cranky 74-yr-old annoying socialist nearly beat the Clinton machine?  (And he might have prevailed if the Democratic National Committee wasn't conspiring against him and he wasn't the victim of an unfair superdelegate system.)  Weren't you as amazed as I was that young people in their 20's favored crazy Uncle Bernie over Hillary?  What was she missing?  

Same issue with Trump who performed the political equivalent of scaling Mount Everest barefoot.  There was a level of disgust and a hunger for change that both parties missed or didn't care about.   Trump voters despised and distrusted the political establishment so much, that his horrendous personal behavior was irrelevant.  He was change, and that's all that mattered.  This is why, I think, that all of those comments that would have sunk any ordinary candidate didn't adversely affect him.

I hope and pray that good will emerge from this.  Both political parties - and perhaps some new ones - will realign and recalibrate and hopefully reach out to the tens of millions of people who deserve to be represented and valued. 

Yes, I know that many feel that they are in mourning now.  Let's hope that he surprises everyone and surrounds himself with wisdom and that he will govern differently than he campaigned. 

For those who suspect that I am a Trump apologist, try again.  I didn’t vote for him.  But, he is my president now, and he’s yours also.

The Republic will survive.   Yes, he will have to be held to his campaign promises, understanding that in every case, it's a lot easier to campaign than it is to govern.  Remember President Obama’s promise to close GITMO in a year?

Finally, let’s celebrate that we can witness a peaceful transfer of power every four years.  We take this for granted, but we shoudn't.  Wanna trade our system for the Philippines, Saudi Arabia, China or Russia?

Sunday, November 6, 2016

Clinton and Trump Give the Nation Chest Pains

Oftentimes, physicians and patients face bad options.  I wish that the choices that patients faced were all good ones, or at least had one option that was likely to yield a favorable result.   This scenario is further complicated as medicine is an uncertain discipline with moving goal posts and changing facts.  We make decisions and recommendations based on the current state of facts and our medical knowledge and experience.  We may counsel a patient against surgery, only to discover days later in retrospect that an operation would have been the right choice.  An adverse outcome may result from an excellent decision. 

There are many medical circumstances when the options are equally foreboding.   A man may be suffering frequent episodes of angina, chest pain caused by hardening of the coronary arteries.  He is on maximal medical treatment, but the symptom persists.  This is not only limiting his life activities and pleasure, but also significantly increases his risk of a heart attack.  His cardiologist has concluded that only a coronary artery bypass operation can help him.  However, the heart surgeon is greatly concerned that because of other illnesses and conditions that the patient is suffering from, that his surgical risks are substantially increased.  In other words, his condition after surgery might be worse than he is now. 


Surgery or Status Quo?

It may be that my hypothetical cardiac patient is suffering from chest pains as a result of the current state of our electoral politics.  Perhaps, his heart has been stressed from failure to accept that the two presidential candidates of our major political parties are the best that this nation produced.   In a country teaming with talent, we are left with two highly flawed candidates who most of us can’t stand.  I surmise that many Americans have developed chest pains and other ailments as a result of demoralizing and dirty politics that each week sink deeper into a slimy abyss.

I cannot count how many of my octagenarian patients - who have never missed a presidential election - are sitting this one out with disgust. 

With regard to this election, I also feel that I face two unpalatable options. How to choose between strychnine or cyanide.  Which option is better, quicksand or a cliff?    

Remember, when we read The Odyssey years ago and read of Odysseus’s ship navigating between Scylla the 6-headed monster and the deadly whirlpool Charybdis?  Two terrible options.  Many Americans today, in an electoral sense, are on a similar journey.


Sunday, October 30, 2016

Clinton vs Trump Agonizes Millions

Physicians and patients often face tough and agonizing choices.  Sometimes, there are no good options available.  On other occasions, there are two seemingly reasonable choices in front of you, but there may be a very different outcome from each pathway.  For example, a patient may be advised by a surgeon to submit to the scalpel while the gastroenterologist counsels to opt for another 48 hours hoping that the medical situation will improve.  Which physician is correct?  They both may be right.  If the patient were to deteriorate 24 hours later, then the operation that had been favored by the surgeon would have been the better choice.  If, however, the patient were to improve spontaneously a day or two later, then avoiding high risk surgery would be clearly favored.

Physicians make decisions based on knowledge and experience.  Often, there is a conflict between knowledge and experience that physicians struggle to resolve.  For example, a doctor may have read in a medical study that a medicine is not effective for a particular condition, and yet his personal experience supports the drug’s efficacy.   Does he deny his own experience and deny his patient the treatment?  And, medical judgement, as I have posted previously, is paramount. 

My points above apply to many professions and, indeed, to the life decisions that confront all of us.  We draw upon our prior experiences, consult others, engage in due diligence, weigh the options and make the best decisions we can based on what is known or knowable at that moment.  A bad outcome may be the result of an excellent decision. 


Clinton vs Trump
Choose Your Poison!

The presidential election that is upon us has posed a conundrum for millions of us.   Who to choose? I have spoken with several octogenarian patients who have told me that this is the first presidential election that they will not cast a vote for either candidate of the two major political parties.  These are not rabblerousing partisans, disgruntled NAFTA haters, culture war mercenaries, anti-immigrants or elderly alt right aficionados.  They are among our ‘greatest generation’ who express disgust and disgrace with the electoral choice that has been forced upon them.  Imagine how they must feel to have never missed a presidential vote in 60 years, until now. 

In my view, no reasonable person can argue that either candidate meets our nation’s highest ideals and values.  Making the case that one’s vote is the lesser of two evils is not exactly a rave endorsement of a candidate.   And, as is always the case, voters and supporters diminish the flaws of the candidate whose politics they approve of, while magnifying flaws of the same magnitude in the political adversary. 

Is not voting for either candidate a defensible and honorable option?

Sunday, October 23, 2016

Sign up for a No Frills Colonoscopy

Cleveland took a major economic hit a few years back when United Airlines cut most of its flights from our city.  An airport is the heart of a metropolis.  Lack of their direct flights means that business meetings, leisure travel, conventions and trade shows will likely opt for more convenient locales. This was a business decision for United which I am sure was rational.  Nevertheless, their gain was our loss.

As a result, we have had several low cost carriers who have swooped in to gain market share.  We have Frontier, Spirit, JetBlue and now Allegiant.  Not a day goes by that I don’t receive an e-mail blast from one of them announcing fares so low that it seems simply not possible.  Many of the flights’ stated fares are less than it would cost me to drive to the destinations.  How do they do it?

Of course, the fare price that is stated is not what you will pay.  The total cost of your flight has been fractionated resulting in an a la carte payment system where every additional service adds to the cost. The airlines justify this with idiotic PR pronouncements that state that this payment system serves the customer who can only purchase the services he actually needs. The fallacy here is that most travelers will need to purchase several airline services, so that the falsely low bait price is deceptive as nearly no traveler will pay it.  I suppose that if you were traveling without luggage, were departing at convenient times such as 2 a.m., eased yourself into the commodious middle seat and brought a carry on piece about the same size of the pencil cases we used in elementary school, then you could actually pay the base price.  If however, you have any checked luggage or carry on items, want to choose your own seat, want enough legroom to allow some circulation to reach your toes, want a beverage, want an oxygen mask that works, want a flotation device that floats, then you will pay for every one of these luxurious upgrades.

Wanna Newer Model?  It's Gonna Cost You!

Even with all of their pick-pocketing, the costs are still generally less than conventional airlines.  But the gap between them is less than you might think.

Perhaps, this is how we should market colonoscopy.

COLONOSCOPY for $49!

Once we’ve signed up the customers, we would review some of the optional services that they may wish to purchase to enhance their colonoscopy experience.  Just like with the airlines, they are free to bypass these extras and can then pay our low base price.  Here are some of the high end upgrades available to those who want a Cadillac colonoscopy.
  • Greeting from the receptionist.
  • A properly disinfected instrument.
  • Supplemental oxygen
  • Sterile needles
  • Economy class anesthesia
  • Business class anesthesia
  • Treatment for side effects of anesthesia
  • Monitoring vital signs beyond initial free blood pressure check
  • Sober nurses
  • Charge for withdrawing the colonoscope.  The base charge only includes insertion of the instrument.
  • Use of the restroom before or after the procedure.
  • Forward report to the referring physician.
  • Explain results to your family members, Base charge includes ‘thumbs up’ or ‘thumbs down’ gestures only.
There’s no reason that this pricing approach couldn’t apply to your business.  Soon, we’ll be reading ads for new cars for $2,500, vacations to exotic beaches for $149, Five Star restaurant meals for $7 and a remodeled kitchen for just $99!

Why not just tell us the truth.  How much extra would that cost?

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