Eli,
How does/will Obamacare change the outcome of your patient in the ICU? How will it change the care of everyone else? That is, will everyone's care suffer in order to reduce the resources spent on the terminal patient you described?
Bill
Wednesday, September 19, 2012
Extremists
Bill,
At dinner with friends the other night I made the mistake of talking about politics. It was a solid lefty crowd, so I thought I was on fairly safe ground mouthing the usual partisan platitudes about the election etc. Somehow the conversation drifted around to economics and the subject of monetarism, of all things, came up. Milton Friedman may have been misguided in some matters, I opined, but he clearly was a gifted and important economist.
"NO!" thundered the host. "Friedman was (and I quote directly) "...among the great charlatans of mid-20th century thought... the true lunatic, which I believe Friedman actually is,... can be identified easily. For the lunatic, everything proves everything else. The lunatic is all idee fixee, and whatever he comes across proves everything else. It makes no difference what the ultimate conclusion is... the lunatic lacks common sense, he takes liberties with what works, he seems inspired at times."
He wasn't done.
"Many people want everyone to make nice and get back to what is imagined as politics as they used to be - a concept sort of like the free market. It simply cannot happen the way the economy is run now. But this redistribution of wealth in favor of the very rich has been at least 30 years in the making. The loss of solid middle class and lower middle class jobs has been at least 45 years in the making. Make no mistake. They will come for the upper tier jobs sooner or later."
The problem with economy in his view is with...
"the 1%-ers. They are anti-Americans, they have their own government that resides globally. They are like the Mafia except their activities are legalized. But they are, by any estimation extortive, belittling, manipulative, and cruel."
And finally,
"Most revolutions, and I'm not limiting myself to "violent" revolutions, are the product of middle and even upper-middle class ferment. As the historians say: the uneducated make rebellions; the educated make revolutions. For every Mao there is a Chou. For every war paint-wearing colonist at the original Boston Tea Party, there was a Madison or Jefferson. Castro's father was quite prosperous.
So this is a man, quite gifted intellectually, who believes that anyone who disagrees with his world view is either stupid or evil or more likely both. He believes that the current state of affairs is the product of an evil cabal of the wealthy (including me by his standards) and that the ultimate solution lies in violence.
My advice to him is go. Go live under the tyranny of one of those revolutionary societies you admire so much. Let me know how you like it, if they let you out.
The fact that he ostensibly represents the left wing of the political spectrum is immaterial. He is the true extremist, with more in common with his fellow fanatics at the other end than the rest of us. They are the 1%ers we truly need to fear.
Eli.
At dinner with friends the other night I made the mistake of talking about politics. It was a solid lefty crowd, so I thought I was on fairly safe ground mouthing the usual partisan platitudes about the election etc. Somehow the conversation drifted around to economics and the subject of monetarism, of all things, came up. Milton Friedman may have been misguided in some matters, I opined, but he clearly was a gifted and important economist.
"NO!" thundered the host. "Friedman was (and I quote directly) "...among the great charlatans of mid-20th century thought... the true lunatic, which I believe Friedman actually is,... can be identified easily. For the lunatic, everything proves everything else. The lunatic is all idee fixee, and whatever he comes across proves everything else. It makes no difference what the ultimate conclusion is... the lunatic lacks common sense, he takes liberties with what works, he seems inspired at times."
He wasn't done.
"Many people want everyone to make nice and get back to what is imagined as politics as they used to be - a concept sort of like the free market. It simply cannot happen the way the economy is run now. But this redistribution of wealth in favor of the very rich has been at least 30 years in the making. The loss of solid middle class and lower middle class jobs has been at least 45 years in the making. Make no mistake. They will come for the upper tier jobs sooner or later."
The problem with economy in his view is with...
"the 1%-ers. They are anti-Americans, they have their own government that resides globally. They are like the Mafia except their activities are legalized. But they are, by any estimation extortive, belittling, manipulative, and cruel."
And finally,
"Most revolutions, and I'm not limiting myself to "violent" revolutions, are the product of middle and even upper-middle class ferment. As the historians say: the uneducated make rebellions; the educated make revolutions. For every Mao there is a Chou. For every war paint-wearing colonist at the original Boston Tea Party, there was a Madison or Jefferson. Castro's father was quite prosperous.
So this is a man, quite gifted intellectually, who believes that anyone who disagrees with his world view is either stupid or evil or more likely both. He believes that the current state of affairs is the product of an evil cabal of the wealthy (including me by his standards) and that the ultimate solution lies in violence.
My advice to him is go. Go live under the tyranny of one of those revolutionary societies you admire so much. Let me know how you like it, if they let you out.
The fact that he ostensibly represents the left wing of the political spectrum is immaterial. He is the true extremist, with more in common with his fellow fanatics at the other end than the rest of us. They are the 1%ers we truly need to fear.
Eli.
In the Intensive Care Unit
Bill,
It's day 8 of my 10 day stint as the attending in the cardiac care unit. I was holding up pretty well until today's admission to bed 8. She is a 90 year old severely demented non verbal lady who dropped dead after breakfast yesterday morning. She was subsequently resuscitated and brought by ambulance to the Emergency Room and then to my unit, where she now lies with a breathing tube down her throat, a catheter in her bladder and all the best (and most expensive) technology that 21st century American medicine can provide. And there she will stay until she dies, which she will likely do despite all of our efforts to prevent her from doing so. All at about 10 grand a day. There is no living will, no previous discussion with family (where are those death panels when you need them?), There are many forms of torture that are less sadistic than what we are doing to this poor woman right now. This is American exceptionalism in its most bizarre incarnation-no one other country in the world allows its old folks to die as gruesomely and expensively as we do
This is where 25% of the Medicare budget is going. That is just nuts. But if the current election is teaching any lesson to future candidates, it is that you mess with Medicare at your own political peril. Neither side is serious about doing anything to change this catastrophic state of affairs.
Good thing I only have 2 days to go. Otherwise I might run into this poor woman's family and give them a piece of my mind about how the hell they let this happen to someone they claim to love.
Eli
It's day 8 of my 10 day stint as the attending in the cardiac care unit. I was holding up pretty well until today's admission to bed 8. She is a 90 year old severely demented non verbal lady who dropped dead after breakfast yesterday morning. She was subsequently resuscitated and brought by ambulance to the Emergency Room and then to my unit, where she now lies with a breathing tube down her throat, a catheter in her bladder and all the best (and most expensive) technology that 21st century American medicine can provide. And there she will stay until she dies, which she will likely do despite all of our efforts to prevent her from doing so. All at about 10 grand a day. There is no living will, no previous discussion with family (where are those death panels when you need them?), There are many forms of torture that are less sadistic than what we are doing to this poor woman right now. This is American exceptionalism in its most bizarre incarnation-no one other country in the world allows its old folks to die as gruesomely and expensively as we do
This is where 25% of the Medicare budget is going. That is just nuts. But if the current election is teaching any lesson to future candidates, it is that you mess with Medicare at your own political peril. Neither side is serious about doing anything to change this catastrophic state of affairs.
Good thing I only have 2 days to go. Otherwise I might run into this poor woman's family and give them a piece of my mind about how the hell they let this happen to someone they claim to love.
Eli
Tuesday, September 11, 2012
The weeks after 9/11 I spent in temporary office space
The weeks after 9/11 I spent in temporary office space. When the towers came down, the force blew through the windows of my office, across the street from the Towers, covering everything with dust and setting off the fire extinguishers, which then drenched whatever remained.
Even if the attacks hadn't precipitated a recession I would have been looking for work. The company I worked for was being purchased. The only question we had was would we be fired by our current company because business was down, or would we be fired by the acquiring company as part of the acquisition synergies.
I spent as little time in my temporary office as possible. I walked. A lot. I should have been looking for a job, but I wasn't. I walked.
There were posters of the lost everywhere. Taped to pay phones, sides of buildings, on bulletin boards. At a Duane-Reade near Union Square on 14th Street the entire north face of the building was covered in posters of people lost in the Towers. Some were "Have you seen?" At the time there was still hope that somehow someone had survived. I approached that wall and the pictures started to come into focus. The closer I got the better I could see how far down the side of the building the posters extended. No, I thought. No. It wasn't possible. It was not possible for this to have happened.
I was lost also, barely alive. On 9/11 I got stuck in Battery Park. We were eventually evacuated, via ferry, across the Hudson, to New Jersey. I sat on that boat and watched the smoke coming from the towers, where my office had been, where my job had been, where my life had been.
I knew it was 9/11 today, but it didn't really penetrate my consciousness until I got on the train this morning. Eleven years ago was very similar to today. It was a beautiful day. The sky was clear, the weather crisp. You could feel Fall coming. As the train brought me into Manhattan this morning, I looked out the window, and saw a plane. I flinched. Then I went back to my reading. I had things to do.
Even if the attacks hadn't precipitated a recession I would have been looking for work. The company I worked for was being purchased. The only question we had was would we be fired by our current company because business was down, or would we be fired by the acquiring company as part of the acquisition synergies.
I spent as little time in my temporary office as possible. I walked. A lot. I should have been looking for a job, but I wasn't. I walked.
There were posters of the lost everywhere. Taped to pay phones, sides of buildings, on bulletin boards. At a Duane-Reade near Union Square on 14th Street the entire north face of the building was covered in posters of people lost in the Towers. Some were "Have you seen?" At the time there was still hope that somehow someone had survived. I approached that wall and the pictures started to come into focus. The closer I got the better I could see how far down the side of the building the posters extended. No, I thought. No. It wasn't possible. It was not possible for this to have happened.
I was lost also, barely alive. On 9/11 I got stuck in Battery Park. We were eventually evacuated, via ferry, across the Hudson, to New Jersey. I sat on that boat and watched the smoke coming from the towers, where my office had been, where my job had been, where my life had been.
I knew it was 9/11 today, but it didn't really penetrate my consciousness until I got on the train this morning. Eleven years ago was very similar to today. It was a beautiful day. The sky was clear, the weather crisp. You could feel Fall coming. As the train brought me into Manhattan this morning, I looked out the window, and saw a plane. I flinched. Then I went back to my reading. I had things to do.
Monday, September 10, 2012
An Act Improving the Quality of Health Care and Reducing Costs through increased Transparency
Eli,
Massachusetts, "An Act Improving the Quality of Health Care and Reducing Costs through increased Transparency" is a preview of Obamacare and IPAB, of course. And it's just as foolish.
The law will limit the rate of growth of health care spending the annual growth rate of the state's GDP through 2017, the GDP less 50 basis points. In layman's language, you already spend enough on health care, so beginning in 2017 you will spend less of your budget on health care. Of course, if the citizens of Massachusetts want to spend more, too bad.
I'm still waiting to hear from anyone why this is good for patients or health care providers.
Here's the part of the bill about the "health planning council." Since the Russians, the Chinese, the North Koreans and the Cubans have had such great success with five-year plans and central planning councils, it makes perfect sense to me we should have a go at it. (Yes, I did choose those countries deliberately).
Bill
Massachusetts, "An Act Improving the Quality of Health Care and Reducing Costs through increased Transparency" is a preview of Obamacare and IPAB, of course. And it's just as foolish.
The law will limit the rate of growth of health care spending the annual growth rate of the state's GDP through 2017, the GDP less 50 basis points. In layman's language, you already spend enough on health care, so beginning in 2017 you will spend less of your budget on health care. Of course, if the citizens of Massachusetts want to spend more, too bad.
I'm still waiting to hear from anyone why this is good for patients or health care providers.
Here's the part of the bill about the "health planning council." Since the Russians, the Chinese, the North Koreans and the Cubans have had such great success with five-year plans and central planning councils, it makes perfect sense to me we should have a go at it. (Yes, I did choose those countries deliberately).
Bill
Section 16T.(a) There shall be a health planning council within the executive office of health and human services, consisting of the secretary of health and human services or a designee who shall serve as chair, the commissioner of public health or a designee, the director of the office of Medicaid or a designee, the commissioner of mental health or a designee, the secretary of elder affairs or a designee, the executive director of the center for health information and analysis or a designee, the executive director of the health policy commission or a designee and 3 members appointed by the governor, of whom shall be a health economist; 1 of whom shallhave experience in health policy and planning and 1 of whom shall have experience in health care market planning and service line analysis.
The council shall assemble an advisory committee of not more than 13 members who shall reflect a broad distribution of diverse perspectives on the health care system, including health care providers and provider organizations, third-party payers, both public and private, consumer representatives and labor organizations representing health care workers. The advisory committee shall review drafts and provide recommendations to the council during the development of the plan.
The executive office of health and human services, with the council, shall conduct at least 5 public hearings, in geographically diverse areas, on the plan as proposed and shall give interested persons an opportunity to submit their views orally and in writing. In addition, the executive office may create and maintain a website to allow members of the public to submit comments electronically and review comments submitted by others. The state health plan shall identify needs of the commonwealth in health care services, providers, programs and facilities; the resources available to meet those needs; and the priorities for addressing those needs.
(b) The state health plan developed by the council shall include the location, distribution and nature of all health care resources in the commonwealth and shall establish and maintain on a current basis an inventory of all such resources together with all other reasonably pertinent information concerning such resources. For purposes of this section, a health care resource shall include any resource, whether personal or institutional in nature and whether owned or operated by any person, the commonwealth or political subdivision thereof, the principal purpose of which is to provide, or facilitate the provision of, services for the prevention, detection, diagnosis or treatment of those physical and mental conditions experienced by humans which usually are the result of, or result in, disease, injury, deformity or pain.
The plan shall identify certain categories of health care resources, including acute care units; non-acute care units; specialty care units, including, but not limited to, burn, coronary care, cancer care, neonatal care, post-obstetric and post operative recovery care, pulmonary care, renal dialysis and surgical, including trauma and intensive care units; skilled nursing facilities; assisted living facilities; long-term care facilities; home health, behavioral health and mental health services; treatment and prevention services for alcohol and other drug abuse; emergency care; ambulatory care services; primary care resources; pharmacy and pharmacological services; family planning services; obstetrics and gynecology services; allied health services including, but not limited to, optometric care, chiropractic services, dental care and midwifery services; federally qualified health centers and free clinics; numbers of technologies or equipment defined as innovative services or new technologies by the department under section 25C of chapter 111; and health screening and early intervention services.
The plan shall also make recommendations for the appropriate supply and distribution of resources, programs, capacities, technologies and services identified in the second paragraph of this subsection on a state-wide or regional basis based on an assessment of need for the next 5 years and options for implementing such recommendations. The recommendations shall reflect at least the following goals: to maintain and improve the quality of health care services; to support the state’s efforts to meet the health care cost growth benchmark established under section 9 of chapter 6D; to support innovative health care delivery and alternative payment models as identified by the commission; to reduce unnecessary duplication; to support universal access to community-based preventative and patient-centered primary health care; to reduce health disparities; to support efforts to integrate mental health, behavioral and substance use disorder services with overall medical care; to reflect the latest trends in utilization and support the best standards of care; and to rationally distribute health care resources across geographic regions of state based on the needs of the population on a statewide basis, as well as, the needs of particular geographic areas of the state.
(c) The department shall issue guidelines, rules or regulations consistent with the state health plan for making determinations of need. If the commissioner determines that statutory changes are necessary to implement the plan, the commissioner shall submit legislative language to the joint committee on public health and the joint committee on health care financing.
(d) The department may require health care resources to provide information for the purposes of this section and may prescribe by regulation uniform reporting requirements. In prescribing such regulations the department shall strive to make any reports required under this section of mutual benefit to those providing, as well as, those using such information and shall avoid placing any burdens on such providers which are not reasonably necessary to accomplish this section. Agencies of the commonwealth which collect cost or other data concerning health care resources shall cooperate with the department in coordinating such data with information collected under this section.
The inventory compiled under subsection (b) and all related information shall be maintained in a form usable by the general public in a designated office of the department, shall constitute a public record and shall be coordinated with information collected by the department under other laws, federal census information and other vital statistics from reliable sources; provided, however, that any item of information which is confidential or privileged in nature or under any other law shall not be regarded as a public record under this section.
(e) The department shall publish analyses, reports and interpretations of information collected under this section to promote awareness of the distribution and nature of health care resources in the commonwealth.
(f) In the performance of its duties, the department, subject to appropriation, may enter into such contracts with agencies of the federal government, the commonwealth or any political subdivision thereof and public or private bodies, as it considers necessary; provided, however, that no information received under such a contract shall be published or relied upon for any purpose by the department unless the department has determined such information to be reasonably accurate by statistical sampling or other suitable techniques for measuring the reliability of information-gathering processes.
Restraint of Trade
Eli,
I knew you had an inner libertarian in you.
You should check out the Institute for Justice:
"Founded in 1991, the Institute for Justice is what a civil liberties law firm should be. As our nation's only libertarian public interest law firm, we engage in cutting-edge litigation and advocacy both in the courts of law and in the court of public opinion on behalf of individuals whose most basic rights are denied by the government--like the right to earn an honest living, private property rights, and the right to free speech, especially in the areas of commercial and Internet speech."
I had the sense you were trying to goad me into something, but I'm tired and distracted, so not quite sure.
Anyway, restraint of trade is bad. Government should stop it. Unfortunately, government typically encourages it.
Bill
I knew you had an inner libertarian in you.
You should check out the Institute for Justice:
"Founded in 1991, the Institute for Justice is what a civil liberties law firm should be. As our nation's only libertarian public interest law firm, we engage in cutting-edge litigation and advocacy both in the courts of law and in the court of public opinion on behalf of individuals whose most basic rights are denied by the government--like the right to earn an honest living, private property rights, and the right to free speech, especially in the areas of commercial and Internet speech."
I had the sense you were trying to goad me into something, but I'm tired and distracted, so not quite sure.
Anyway, restraint of trade is bad. Government should stop it. Unfortunately, government typically encourages it.
Bill
Why Do Doctors in America Make So Much Money?
Bill,
When I was in medical school I read a book that influenced me greatly, called The Social Transformation of American Medicine, written by a sociologist named Paul Starr. Starr, now a professor at Princeton, and an icon of the American left, postulated that the fabulous economic success of American physicians was largely a product of fortunate circumstance and skillful self protection, beginning with state licensing of doctors in the 19th century. According to his thesis, licensing, while ostensibly designed to protect patients, effectively served as a barrier to competition , and thus lifted the wages of those able to obtain a license. As a guild comprised mostly of small businessmen, physicians were ultimately happy to embrace the benefits and status that licensing conferred.
Imagine my surprise (and perhaps Starr's as well) when I encountered following discussion of licensing on a libertarian website. It seems that on this questions both left and right agree. Guilds, whether composed of hairdressers of heart surgeons, will do what they can to limit competition and thus maximize their earnings and autonomy. And who can blame them? They are merely playing their role as rational economic actors. If the public is protected from charlatans (as it surely is in the case of doctors) that's a secondary benefit
peripheral to the primary purpose of licensing itself.
You describe this paradox elegantly in your discussion of organized medicine's long and effective history of protecting its interests (even when its perception of that interest is misplaced), and the disadvantages to consumers/patients that that limitation of completion produces. There is no reason why, for instance, it should be so difficult to get an appointment with a dermatologist, or why it should cost so much when you do get one. Derm, as its known, isn't that hard. Basically everybody with a rash gets steroids or antibiotics or both. But the American Academy of Dermatology has masterfully limited keep the number of training spots low enough to insure that this remains the perpetual state of affairs.
But I can't resist asking (sorry, it's congenital); isn't this what we docs are supposed to be doing in a liberated economy? Isn't this what any self-interested group like, say stockbrokers will do if it can? And isn't the only effective countervailing force to restriction likely to be government (there, I have left myself well exposed for your riposte)?
Those conditions are rapidly are changing you may be happy to know, as the status of American medicine is relentlessly eroded by forces much larger than itself. The number of American physicians in private practice has dropped to less than 50%, and is surely destined to drop even further. Wages, which peaked in the early 80s, are falling in sync. So no matter who controls the health care agenda, docs will be doing what we do for less. Whether we do it any better remains to be seen.
Meanwhile, on Aug 6, Deval Patrick signed S. 2400, "An Act Improving the Quality of Health Care and Reducing Costs through increased Transparency" into law.
Eli
When I was in medical school I read a book that influenced me greatly, called The Social Transformation of American Medicine, written by a sociologist named Paul Starr. Starr, now a professor at Princeton, and an icon of the American left, postulated that the fabulous economic success of American physicians was largely a product of fortunate circumstance and skillful self protection, beginning with state licensing of doctors in the 19th century. According to his thesis, licensing, while ostensibly designed to protect patients, effectively served as a barrier to competition , and thus lifted the wages of those able to obtain a license. As a guild comprised mostly of small businessmen, physicians were ultimately happy to embrace the benefits and status that licensing conferred.
Imagine my surprise (and perhaps Starr's as well) when I encountered following discussion of licensing on a libertarian website. It seems that on this questions both left and right agree. Guilds, whether composed of hairdressers of heart surgeons, will do what they can to limit competition and thus maximize their earnings and autonomy. And who can blame them? They are merely playing their role as rational economic actors. If the public is protected from charlatans (as it surely is in the case of doctors) that's a secondary benefit
peripheral to the primary purpose of licensing itself.
You describe this paradox elegantly in your discussion of organized medicine's long and effective history of protecting its interests (even when its perception of that interest is misplaced), and the disadvantages to consumers/patients that that limitation of completion produces. There is no reason why, for instance, it should be so difficult to get an appointment with a dermatologist, or why it should cost so much when you do get one. Derm, as its known, isn't that hard. Basically everybody with a rash gets steroids or antibiotics or both. But the American Academy of Dermatology has masterfully limited keep the number of training spots low enough to insure that this remains the perpetual state of affairs.
But I can't resist asking (sorry, it's congenital); isn't this what we docs are supposed to be doing in a liberated economy? Isn't this what any self-interested group like, say stockbrokers will do if it can? And isn't the only effective countervailing force to restriction likely to be government (there, I have left myself well exposed for your riposte)?
Those conditions are rapidly are changing you may be happy to know, as the status of American medicine is relentlessly eroded by forces much larger than itself. The number of American physicians in private practice has dropped to less than 50%, and is surely destined to drop even further. Wages, which peaked in the early 80s, are falling in sync. So no matter who controls the health care agenda, docs will be doing what we do for less. Whether we do it any better remains to be seen.
Meanwhile, on Aug 6, Deval Patrick signed S. 2400, "An Act Improving the Quality of Health Care and Reducing Costs through increased Transparency" into law.
Eli
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