Oh Henry
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Thoughts on states’ rights, resource allocation, and why Iowa is a little slice of heaven.   

If government is the answer, just imagine how stupid the question is. George Orwell was correct when he commented: “In a time of universal deceit, telling the truth is a revolutionary act.” Disinformation – or non-information – is everywhere. Most 24-hour news is 24 hours of crap. 

Last week, in American Medical News (a well-known radical journal), a report was published that looked over the health statistics of the “Gang of Seventeen.” These are the seventeen Western democracies that we tend to view as the “civilized world,” and with whom we are constantly comparing ourselves. Get the piece. Read it. Study it. It is both frightening and illuminating. Not only do we have the most expensive healthcare in the world by more than double our nearest competitor, but also the worst results. Male longevity: 17th of the 17 countries. Female longevity: 17th of the 17 countries – although women do live slightly longer than men. Infant mortality? Again, we’ve taken the bottom of the barrel. Need we go on here? We are led by people who think that by calling it the “Affordable Care Act” we would all be dumb enough to think it had something to do with health or care. Nothing could be farther from the truth. This is a massive effort to avoid looking at the causes of life, death and transfiguration. This is political-speak in the extreme. It’s like Stalin telling his people they were building the Great Society. Or was that Lyndon Johnson? Geeze, I’ve forgotten.

So, who is leading this peripatetic healthcare parade? What are the harbingers of collapse, and how do we now move to rectify the problem? First, we need to ask where this problem has come from. Most who have recently held or now hold leadership positions are the descendants of the “greatest generation.” Remember those poor people who lived through the Great Depression and fought the Second World War and built the country? They gave to their children everything but poverty. And that’s too bad because they needed a little poverty desperately. They are the snot-nosed kids who got everything they wanted – like top flight educations – and never really asked where the money came from. Most of them couldn’t use a wrench or a screwdriver if their life depended on it. So, now the progeny of the Greatest Generation – which has taken the field and believes it’s running things – want to “do what they think is right.” You mean we have to make choices? You mean we can’t create our own reality? You mean we can’t get a degree in primal scream masturbation and its influence on progressive deconstructionism and expect to get a job on the way out the Ivy-shrouded doors?

Our generation – and I include myself – really only had one motto: Nothing succeeds like excess. The concept of being concerned about caring for the young in a realistic, substantial way and caring for the old by taking them back into our homes never really dawned on anyone until now. Funny thing: If you hang around long enough, you get old. Now these issues are staring us in the face. We are looking down the barrel of policies and concepts which substantially have forced those of us in the United States to deal with one factor: The dependency ratio. The relationship between those pulling the wagon and those sitting in the wagon of economic recovery has now fallen to below two. This is a number which economists have long anticipated would precipitate some serious calamity. The real question we are asking as we consider these numbers is: Can they actually be correct? Who’s going to take care of us, and why can’t we have all the healthcare we want, even if most of it doesn’t work? Americans have been cowed and manipulated by meaningless non-science. If we can put men on the moon, why can’t we fix grandma? Oh, if only it were that simple.

As an aside, I would like the readers to now take one minute and decide how they want to die. This is an important question since you are going to die at some point in time. How much should it cost and who should pay the bill? None of these issues were contemplated in the Affordable Care Act, and now it’s coming home to roost. We are now told, the way the Act it is currently constituted, the cost was underestimated by at least 40%. What are we going to do about this? There seems to be a total abandonment of the entrepreneurial spirit that says: “We can do it better, cheaper, faster and smarter.” As soon as “big government” gets involved, no one seems to care. Backing up the report in the American Medical News was the March 2012 publication by the Commonwealth Fund. For those of you unaware of the Commonwealth Fund, understand that its only job is looking at what can make this a better country and world. Get a copy of this report and study it carefully; it is the principle basis on which healthcare will go forward over the next few years. They have rated healthcare in America by 43 different aspects. They’ve divided the country into 306 regions (i.e. groups of populations) for study purposes.

Let’s take a look at the study. It’s amazing how often Dubuque, Mason City and Iowa City come to the top of the list. They are almost the lowest in cost and best in outcomes in healthcare in the United States. Of the big cities, why should Minneapolis and St. Paul be so high in both quality and low in cost while Miami is exactly the opposite? Why should it cost three times as much for a senior to get healthcare in Miami, Florida? No one raised these issues during the healthcare debate, and quite frankly, it is not only killing our seniors, it is killing our children and their future. Top of the list for quality? Green Bay, Wisconsin. Down at the bottom? Houston, Texas. And Houston has a lot more doctors per person than Green Bay. Maybe it’s the cold weather in Green Bay. All the bugs are killed in the winter so you don’t need antibiotics. It’s hard to know, isn’t it?

The Congress of the United States is afraid to turn things back to the states. America is not a homogenous culture. We have regional differences. Why do you think that hardworking, fiscally responsible and healthy citizens of South Dakota should sub-fund the non-intelligent and nonproductive healthcare of Miami, Florida? If Miami actually had to pay its own healthcare bills instead of stealing money from Montana, they would be forced to raise the amount they pay or look for some innovative way to change their behaviors.

In 1960, when I was in 8th grade, I took my first combination economics and government course. I remember vividly the pie chart on federal spending for the year 1960. Defense constituted 52 percent of all federal spending. Today, that number is between 19 and 20 percent, depending on what you count. Defense will be number three this year in the federal budget for the first time in the history of the United States. Entitlement programs, which include Medicare, Medicaid and Social Security (not including federal retirement benefits) will be number one. Close behind, at 20 percent, will be the interest on the national debt. That’s right. For the first time in our history, since the first shot of the Revolutionary War, we as a people will be spending more on the interest of our largess than in defense of these shores.

Doctors were once known as “can do” people. We are now known as “can’t do unless we have fifty more tests” people. Physicians have the destiny of the union in their hands. We are the big ticket item and we need the moral fortitude and courage to occasionally say “no more” to minimally effective medications and useless end-of-life therapies.

I know that you’re thinking: “I’ll do the right thing when they put the lawyers in cages.” Is the current medical/mal system broken? Yes. Move on. Does that mean we can blame everything on the lawyers? No. We are complicit in this problem and must accept the fact that we have totally disregarded our job and stewardship of the resources of the United States. Until we get the system we need, just remember that we win most of the time in court. If you’re going to get sued, at least get sued for doing what’s right.
Pro bono publico

 

Comments   

# A Treatise on Medical Stewardship commentaryLarry Lewis 2013-03-13 09:05
Dr. Henry is nothing, if not provocative and entertaining, but the ramblings do not make a coherent argument against government programs.
He appears to blame the ACA for our poor health rankings vis a vis other rich countries. Our poor health outcomes and excessive costs compared to other wealthy nations were recognized long before the ACA became law, and in fact was a strong argument for this change. I would agree (if this is even a point Dr. Henry was trying to make)that The Patient Protection and Affordable Care Act is much clearer on how it accomplishes the former (protecting patients) than the latter. But it is well known that administrative costs are higher for private insurance plans than for government-run plans (Medicare and Medicaid). Dr. Henry does not mention that the 16 countries against which we are compared for healthcare costs and outcomes have government run healthcare systems.
Dr. Henry spends some time on the implications and cost of dying. We should all recall that when the ACA was proposed, there was reimbursement for end-of-life counseling and decision making, but this led to an outcry of "death squads" by the opposition and was dropped. Clearly, addressing end-of-life issues can help reduce healthcare costs without sacrificing quality. But there are a number of other ways to reduce costs without reducing quality or most reimbursement. This includes looking at ways to reduce the cost of caring for the highest end-users. 1% of the people account for between 20 and 25% of all healthcare costs, and the top 5% of users account for 50% of costs. Analyzing the causes for this, and trying to develop cost-effective ways of addressing them are imperative for cost reduction that maintains or improves quality. There are a number of other issues in the piece with which I partially or wholly disagree, but I will only address the budget. Defense is still the biggest single expense in the budget by far, being over 3 times the amount spent on the national debt interest, and of course is a major factor leading to the increasing debt (see figure). Do we really need to spend more on defense than the next top 10 countries combined? There are some nice sound bites in the Treatise (If government is the answer, just imagine how stupid the question is). What exactly, does this mean? Does Dr. Henry think the NIH, CDC, and FEMA are not answers to particular problems? We don't need more sound bites. What we need is thoughtful and unbiased study to determine and implement the best solutions for the very difficult problem of controlling healthcare costs while maintaining or improving quality. I believe it can be done, and that government must play an important role.
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# Ben Rush MD 2013-03-17 04:31
You don't need to put lawyers in cages. Merely institute "Loser Pays." something already in place in the rest of the world. Next, pay physicians for the time spent with the patients, not arcane and arbitrary CPT codes. This would end the "15 Minute Visit" treadmill. Finally, we and our leaders must realize that healthcare seems the only enterprise which claims to save money by increasing the number of middle men.
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