Category Archives: Socialized Medicine and other Bad Ideas

The Best-Laid Schemes O’ Mice an’ Men Gang Aft Agley (And Other Things)

(With apologies to Robert Burns. -PB)

Less is Better

I imagine that some day Graham, the author of the superlative medical blog Over!My!Med!Body, who is just now emerging Siddhartha-like from the palace of his father to see the world-as-it-really-is rather than how he wants it to be, is going slam his imported microbrew down on the bar of his favorite San Francisco bistro and announce to his friends that the problem with medical care is “All them goddamn free-loaders mooching off the system,” after which he will stagger to the registrar of voters, change his registration to “Libertarian,” and have his designated driver scrape the Obama bumper sticker off his Prius. He’s certainly headed in that direction, especially on perusing one of his latest articles on futile care where he correctly identifies the disassociation between cost and effectiveness of much of what we inflict on patients in their twilight years. He’s also slowly gaining awareness that many of our patients, far from being poor-but-noble victims of the brutal society in which we live are, in fact, shameless opportunists who will take and take all of the government freebies social justice that they can get their hands on.

In other words, he is slowly, oh so slowly, seeing the obvious: That the problem is one of demand and cost, not some nebulous failure of social justice or systematic oppression. Sure, we can blame insurance executives with their multi-million dollar severance packages and greedy physicians opening specialty centers and concierge practices but the fundamental problem is that everybody wants all the medical care they can eat but nobody wants to pay for it themselves. Hey, it’s a right after all. We don’t have to pay for our freedom of speech and since burning an American flag only costs a few bucks, why should we pay a dime for medical care?

I mention this because it’s an excellent series of articles, by themselves justification for including him on my blogroll, full of bang-on insights to some of the problems of American medical care, many of which I agree with wholeheartedly. You all know my views on futile care for example but Graham and I also share a disdain for Direct To Consumer drug advertising, a practice which I think is ridiculous on so many levels that I hardly know where to begin. Now, as a rapacious, right-wing, pro-industry capitalist who will kill a million caribou without a qualm to drill for Alaskan crude, like Nixon going to China, I probably have a little more…I don’t know…maybe we’ll call it “authenticity” than Graham when it comes to attacking a cherished part of our capitalistic system but Graham still knows of what he speaks.

My only qualm with Graham is the general impression one gets that every solution to every problem is going to involve a whole lot more government involvement. In other words, to decrease the amount of fraud and abuse in whatever socialized or quasi-socialized (or we-swear-it-isn’t-socialized) system the TPGA-axis eventually forces on us Graham would likely turn to the gubbmint’ to implement some byzantine regulatory solution in whose labyrinth will vanish whatever efficiency, flexibility, and innovation is left in our system. It cannot be otherwise. Governments do not give money to anyone willingly, despite the promises of politicians, and money is scarce and getting scarcer. The fundamental problem, in fact, and almost the exclusive preoccupation of every Western Democracy is how to buy off their citizens, to whom were promised lavish social welfare benefits, with treasuries that are becoming rapidly depleted. Covertly or not, medical care and other freebies need to be rationed and governments, to avoid admitting that they’ll be putting down yer’ granny, disguise rationing behind impenetrable bureaucratic obstacles. In Greece, for example, my ancestral homeland and the poster-child for Socialism Gone Wild, while everybody gets free medical care, unless you can fork over a bribe or belong to one of the 149-or-so trade associations with good insurance plans (kind of like co-ops, many of which have failed to the extent that they are all going to be nationalized shortly into about a dozen broad associations), your wait-time for a major operation that even our winos can get in less than a day can be months or years.

That maybe what we need to do is decrease the amount of government involvement in medical care is never seriously considered by anybody, at least not anybody who has a decent chance of doing anything about it. The conventional wisdom upon which every major politician from both parties operates is that government has to do something, the exact something although it may vary is still usually just a question of how much more, not whether it needs to be done at all. For my part, while I think that both Graham and I agree that few can really afford a major hospitalization or the high cost of getting old and multiply comorbid, I have never understood the lust of the wonketariat to provide comprehensive medical insurance for free to everybody whether they need it or not. Surely we will always have some unavoidable costs in our system that the tax-payers will have to suck up. There are many people in our country who are not only poor but completely helpless, conditioned by years of mammary government to be incapable of solving a single problem in their lives without guidance and support from a bureaucrat. The elderly at the other end of the spectrum, many of whom have not contributed nearly as much into Medicare, both from payroll deductions and premiums, as they will eventually use need to be supported as do those who are struck, from out of the blue, by a debilitating illness that leaves them incapable of productive work. To let people die because they can’t afford life-saving treatment, while not exactly a mortal sin against the capitalist ethos, would nonetheless be demoralizing to our nation and only the most Borg-like of Ayn Rand followers would think otherwise. But why compound the problem, why run up the tab on obligations that we cannot possibly meet, by giving away medical care to those who can pay for it themselves? In other words, why bankrupt the nation to ensure that nobody ever has to decide between cable television and taking their kid to the pediatrician?

Which is kind of the choice many of our citizens make, the mantra of the middle class in particular being “Thousands for Personal Watercraft but not a Dime For My Doctor.” Primary care on an individual basis is not that expensive and we are not a nation of paupers. In a country where even the poor can drop a couple of hundred a month for luxuries, things like ringtones for their cell phones and designer clothes, why Graham or anyone agonizes over the best way to make sure that nobody has to pay a dime for medical care if they don’t want to is inexplicable. They’re just not giving people enough credit, displaying the suffocating paternalism that is the hallmark of those with a religious faith in the power of government to solve problems and whose fear is that most of the sturdy and not-so-sturdy yokels, if allowed to make their own decisions about medical care with their own money, will let their children suffer and their own health deteriorate before they’ll spend a dime of their beer money.

Can’t have that of course. People making rational decisions about how they’ll spend their own money. Pandemonium would ensue! The Apocalypse! Panic in the streets! Human Sacrifice! Dogs and cats living together! But, if primary care is relatively cheap and getting cheaper with the advent of four-dollar generics at the shopping Mecca of your choice, where is written that people need expensive comprehensive medical insurance or that the taxpayers, through the sausage-nozzle of government, have to pay for it? If you give a crap about your health, by definition you will pay a hundred bucks every now and then to see your doctor and twenty bucks a month for the (hopefully) minimum amount of medications she deems necessary to control your potentially dangerous medical conditions. If you don’t give a crap you won’t pay which is a personal problem, nothing more. People don’t want to pay because they have been conditioned, first by fifty years of comprehensive medical insurance as a de facto condition of employment and lately by the munificent hand of government that lets them present to the Emergency Department with a complaint of “My ass is sweating” without being arrested for embezzlement of public funds, to expect medical care to flow as effortlessly and cheaply as water from a tap. There is, you understand, a certain transparency to public utilities. Water comes out of the faucet and is carried away to Candyland by the toilet and people don’t really think about it. These things just exist which is how many in the public would like to view medical care, an endeavor which requires several orders of magnitude more money and effort than providing water.

For both mice and men, the best-laid plans often go astray. Unintended consequences flourish, particularly when government which is largely staffed by people who are not qualified for any other job but public service gets involved and tries to control behavior with complicated schemes. We have a nation of unmarried teenage mothers and ruinously expensive government health care grown to a hundred times its most pessimistic projected cost to remind us that socialism is a moth-eaten, half-starved, unpredictable tiger that once let out of the cage is almost impossible to put back in. It’s an economic theory entirely built on the mistaken idea that people will cheerfully and willingly work long and hard to support people they have never met and who don’t do anything for them in return. It is, finally, a philosophy which is turning the West into a nothing more than a crappy nursing home, full of people without the foggiest notion how to be productive and look after themselves, and paid for by money borrowed from the Sheiks of Araby and the Mandarins of China who will eventually decide that paying for the cradle-to-grave benefits of a French poet or the inhabitants of a trailer park in the vast, empty wastes of Massachusetts is not such a good investment. Unfortunately, Western socialism is financed with borrowed money and is therefore unsustainable, especially as economic growth cannot keep up with the growth of entitlements.

It would be a simpler, cheaper, and, as our country is terrifically overdoctored and overmedicated, probably not even detrimental to the aggregate health of our nation if the government withdrew from as much of the medical industry as possible and instead, if they can’t resist the temptation to tinker, enacted policies that encouraged people to pay for as much of their own medical care as possible. Nobody, for example, except the very poorest (to be determined by Graham’s compassion Gestapo) should have a dime of their primary care paid for by the the government on any level. If you need to go the doctor for a cold or to check your blood pressure, you need to pony up. If the government has to be involved, and as most of us agree that a major illness or two will wipe out most people, it can guarantee the solvency of high deductible, major medical policies that citizens would be expected to buy for themselves and their families. Maybe even make it mandatory, call it a tax, and be done with it. We can always take it out of the Earned Income Tax credit for the majority of Americans who, in fact, pay no income tax whatsoever.

On the carrot side, we can encourage health savings accounts from which primary care and other medical expenses can be payed without involving the complicated dance of the bureaucracy, the idea being to encourage the health care market to be a little more transparent and rational. If you’re spending your own money, maybe you don’t want all of those marginally useful treatments and studies.

Of course, medical care is still going to be horrifically expensive. Things cost what they cost and it is impossible that the elderly and their lobbying groups will accept the kind of rationing that is needed to really control spending. Maybe when I get to be seventy I’ll also want my share of heart caths and joint replacements so all of us have a terrific self-interest in supporting our current high-tech and highly expensive medical system. But if a few simple reforms (simple conceptually but almost impossible politically, I mean) to include tort reform could shave twenty or thirty percent off of our current two trillion dollar per year spending spree, that would be enough to keep things solvent.

Other Blogs You Should Read

The best blog on my blogroll, the Macho Response, is not even a medical blog but rather the observations and reflections of a guy living deep in one of the many strongholds of the lunatic fringe and who is slapping them around as they deserve and to the best of his abilities. I’m sure we don’t agree on everything. The Crack Emcee, as he styles himself, is an artist, a musician, and an atheist while I am tone deaf, art-insensate, and a devout Orthodox Christian…but I ain’t a fascist and there is plenty of room in my mind at least for some reasoned differences of opinion. The Emcee is nothing if not reasonable which is not to say that he doesn’t, in a commendable macho fashion, disembowel the usual sensitivity fascists, self-help gurus, and the obnoxious cult-like behavior that is the norm among many of our elites. Sometimes even reasonable men must run up the Jolly Roger, spit on their hands, and commence to cutting throats (If I can paraphrase H.L. Mencken).

You also need to read, regularly, the Happy Hospitalist. I used to think I could write a good article or two but now I must cower in shame in the long shadow of a guy who can really break things down to their most basic level and demonstrate not only what’s wrong with them but what would be required to fix them. My non-medical readers need to go over there because most people who are not involved in medicine have no idea of the obstacles put in the path of a typical private practice physician by the same people who wonder why there aren’t enough doctors to go around.

I have to plug Kevin, MD of course because he is the Don Vito Corleone of the medical blogosphere and he promised to send some of his capos over to break my kneecaps if I didn’t.

Do It for the Children

I’m still looking for more advertisers. I like writing my blog and I hope you folks enjoy reading it but it can be something of chore, not to mention that my wife wonders why I spend so much time doing it instead of surfing for internet porn like normal husbands. At least if I make some money it won’t seem so weird.

Advertising inquiries can be directed to [email protected] I am getting about 30,000 unique visits a month (according to Sitemeter) so while I am not in the Kevin, MD league maybe we can talk.


Rocking Your Fragile World-View

Let us again consider Albania, a tiny country tucked into a little corner of Europe which is only now emerging out of the communist Dark Ages in which it had stagnated while the rest of Europe moved on. This very poor country sits on the Northern border of Greece for whom it serves as a sort of Balkan Mexico, sending a steady stream of poor illegal immigrants into Greece looking for a better life and overwhelming the Greek welfare state. The average life expectancy (a statistic that sleek United Nations bureaucrats and the People Who Love Them use as a surrogate indicator for the quality of a nation’s health care system) of an Albanian is close to 78 years. A typical Frenchman, since France is held to be some sort of medical Shangri La by many Americans, can expect to enjoy pointless cinema, runny cheese, and l’ennui francaise for around 79 years. The typical American might live a few months less than a Frenchman or other comparable European but he can reasonably expect to live as long as an Albanian as will the typical Greek. The United States spends the most per capita on medical care followed by the French, the Greeks, and lagging way, way behind, the hardy Albanians who, despite spending less per capita on medical care than many Americans spend on frothy coffee drinks, still manage to hang on for a long life that is only a matter of months shorter than that enjoyed by a Frenchman, a Greek, an American, or just about anybody in the the rest of the developed world.

Indeed, those thrifty Albanians manage to spend less than 400 bucks apiece per year on medical care, have almost none of the advanced treatments available in the United States or the European Union, very sketchy access to doctors, and still manage to live long, healthy lives eating their Tavi Kosi and smoking their harsh Red Star Tractor Brand unfiltered cigarettes. By comparrisson, we spend close to 6000 bucks per head per year, the Greeks spend about 2500, and the effete French spend around four thousand. If you look at the rest of the developed world, there appears to be a similar discordance between health care exenditure and longevity. Past around six hundred bucks, typical of most of the Balkans and other emerging European nations that have reasonable sewage and other public health measures, there doesn’t seem to be much of correlation between spending and longevity. Maybe a two or three year difference between the top and the bottom which shouldn’t be anything to get excited about. I can easily think of a couple of cultural factors that might account for a bit of this slight difference. In the United States, for example, every Tupac harvested early to the Lord in a pointless rap war, besides being a mighty blow to the music world, drives down the average life expectancy.

I have also never seen, in all of my extensive travels in Europe, anything remotely similar to the four or five-hundred pound behemouths that roam the American landscape in vast herds, making the buffet lines tremble from the thunder of their comfortable shoes and darkening the parking lots of all-you-can eat waffle joints across the fruited plains. I mean, I’m treating obese kids with with type II diabetes, most of whom have free health insurance via medicaid and of which their parents avail themselves with the same gusto they otherwise reserve for nacho cheese biscuits. Lack of health care is not the problem here, nor is access.

In earlier articles I have suggested that we waste a lot of money in the medical industry. How much, exactly, I am unsure. There is a large gray area between what I would consider the completely appropriate use of medical resources and what I know to be the equivalent of flushing burning hundred-dollar bills down the toilet. But I think that most of my learned colleagues on the medical internet will agree that wasted money accounts for a horrifically large percentage of our total two-trillion-dollar yearly spending binge.

Oh my loyal and long-suffering readers, you who I delight in entertaining with detailed prose as I attempt to wrap the truth of the world, or at least how I see it, in a little bit of humor, a little bit of sarcasm, and a little bit of shameless pandering to the understandable instinct to despise the French; I confess from the depths of my black, misanthropic heart that I am not much of a writer. I try hard, of course, and I can occasionly tame an idea or two in my brain long enough to lead it to paper but since I am having a hard time thinking of a clever way to illustrate exactly how much money we waste in this country on medical care, I’m just going to say it plainly with no art or interesting literary devices. Just Keep in mind two things. First, I’m going to tie it all in to the Albanians and second, every patient I’m going to describe costs the system money even if they are what is optimistically called self-pay (a cheerful euphemsism for “There is No Way in Hell I Would Pay a Dime for my Medical Care”). The temptation is to say, “Well, since they can’t pay there is no money changing hands and therefore no real cost to the health care system.” This, however, is a stunning example of wrong-headed thinking. Every patient costs money to somebody if only because the infrastructure to deal with them has to be maintained. Of all the individuals and organizations involved in delivering medical care, the only ones who will work for nothing are doctors. Try getting a nurse or a radiology tech, for example, to work a few extra hours or fill in some holes in the hospital’s schedule for free. They’d laugh, as would the janitors, clerks, and even the nice ladies slinging the chili mac down in the cafeteria. Medical care is a huge team effort involving expensive infrastructure and many highly skilled and not-so-skilled people, none of whom would even consider volunteering their time except, as I mentioned, physicians who are not only regularly asked but expected to work for nothing as the need arises (a typical Emergency Physician working on a production basis and not as hospital employee, for example, gives away a hundred thousand bucks of his time every year).

So let me just state that In the United States, we are terrifically over-doctored. Much of what we spend is to overtreat either self-limiting things or to throw marginally effective therapy, at least in regard to decreased mortality, at chronic medical problems, most of which are lifestyle related. Either that or we burn through money like drunken sailors on futile end-of-life care for people who have absolutely no quality of life unless we are now measuring quality by how long you can lay motionless in your own urine before a minimum-wage nursing home caregiver decides to roll you around a little. Let me give you a few examples of typical patients to illustrate the many ways in which your money is squandered.

“There, you see? She blinked! I love you Grandma!”

I see this patient or some variation at least once on most shifts. An incredibly frail, some might say cadaverous, woman, somewhere in the neighborhood of ninety who has been in a nursing home for a decade and was doing all right with her end-stage renal disease, advanced senile dementia, and congestive heart failure until about a year ago when something broke loose during dialysis and she suffered a stroke, turning her from a demented elderly lady who had broken her hip twice to a demented, aphasic, ancient lady; completely immobile except when indifferently turned by the staff of the warehouse in which she is stored. Because she can no longer swallow the surgeons obliged her family with a PEG tube (to pour liquid food directly into her stomach) and to protect her airway she breathes humidified oxygen through a tracheostomy (a hole in her neck, with another tube sticking out of it). On a philosophical level we can debate the nature of quality of life but I’m going to go out on a limb here and suggest that laying in your own feces on eroded bed sores is not much of a quality of life. In other words, we’re not talking about a hale and hearty nonagenarian who will live to be a hundred provided she can avoid being admitted to the hospital. This is a patient who is living on borrowed time, one who will not last another six months despite our best efforts and yet, in those last six months we will spend large sums of money on her, probably more than the total spent in her whole pre-stroke life, in an inexplicable quest to stave off death, spending money at an increasing rate the closer she gets to actual “reaper” death and not the living death to which she is condemned.

It is also both amusing and edifying to peruse a list of her medications which, after a decade or two of failing health, has grown into a two-page manifesto, a declaration or our faith in evidence-based chemistry. For starters she is on three-hundred dollars a month of Namenda, a new drug that is only marginally effective in improving the memory of patients with early Alzheimer’s but, if you think about it, is kind of ridiculous to use in a patient who is so far gone that even before her stroke she couldn’t even remember how to feed herself. Because of her cardiac history, she is on the obligatory statin and beta-blocker although against what looming cardiac event we are protecting her is not clear. Because of her atrial fibrillation, for which she recieved an implanted defibrillator two years ago, she is on coumadin. Now that she has no risk of ever getting up to fall it has been cranked up, giving her the occasional gastrointestinal bleed as her doctor disinterestedly tries to control her wildy fluctuating levels. As a little bit of seasoning she is on the digoxin to keep her heart beating as well as the usual four or five narcotics which are poured carefully into her feeding tube at regular intervals with the rest of her medications.

We pour expensive medical care into her in equal measure. The PEG and tracheostomy are only the latest procedures. If the squad of specialsts following her play their cards right, she’s good for at least a few bronchoscopies, an echocardioram, and maybe even a battery change on her defibrillator before they’re through

And she’s a full code. The family wants “everything done,” no matter what, up to and including artificial ventilation, defibrillation, and even more tubes. You see, “She knows we’re in the room, doc. Can’t you see how she perks up when we speak?” Against this kind of faith there is no argument possible, not in our totally out-of-control health care system where, since somebody else is always paying, money is no object. I have no doubt that the last six months of her life is going to cost a couple of hundred thousand dollars. A day in the intensive care unit by itself costs a cool four grand. She will probably burn through a couple of weeks of these before the final, terminal admission where at last, somebody has the common sense to say “no mas” and, after one final orgy of spending (for old time’s sake), we finally let her go.

Where’s the Fire?

Every now and then our already busy Emergency Department is innundated with a surge of patients. The waiting room is packed and the over-flow are seated in folding chairs in the hallway. The chart rack spills over, five rows deep instead of the usual two and you’d think a plane had crashed or the Four Horsemen were abroad. A quick survey of the new charts, however, shows the usual minor complaints, things that eventually turn out to be colds or vague abdominal pain. The panic begins, tempers get short, and, already working at a dangeorus speed, we are expected to double our efforts and move patients. God forbid we get a critical patient at a time like this because that will gum up the waiting room to an unacceptable degree. Why, and please try to choke down your horror, people with minor complaints might even get tired of waiting and leave the department without being seen. Which is sort of the problem. While it is no doubt true that hidden among the irritated patients spilling into the hallway is a real, honest-to-God heart attack or a smouldering acute appendicitis about to become dangerous, the majority of the deluge are patients with complaints that turn out to be minor, self-limiting things or even no problem at all except the siren call of the only representative of the all-giving and all-powerful Man that is open at 2 AM.

Now, I’m not saying that patients don’t need to be seen. Many have no other access to medical care and some are really quite sick. Although I would hate for the Emergency Department to become a primary care clinic for the indigent (a direction towards which we are lurching as hospital bureaucrats think up even more ways to jack up Press-Ganey scores), there is a need for medical care that somebody has to fill. On the other hand many of the complaints are so minor that they don’t need to be seen at all, even if the patient has premium insurance and is followed by the best internist in town. A request for a pregancy test, for example, should never make it past triage. Likewise what is obviously a cold in an otherwise healthy young adult. It is true that both of these complaints might be more than they seem, the pregancy may be an ectopic and the cold may be a Wegener’s friggin’ Granulomatosis but that doesn’t mean that they need to be worked up, a difficult concept for people to understand.

Or, to put it another way, if we work up every minor complaint under the sun looking for a big, bad, macho, internal-medicine-type thrill kill we won’t miss it when it pops up but we are going to have a horrifically expensive health care system with money being spent where it will do the least good. I’m not implying that every cold gets the million dollar workup. We still have a little common sense left. But these patients are dutifully triaged and seen, leading to crowding in the department, already more than a little constipated with “Emergency Department Admissions” (patients with orders for admission but no available beds or nurses in the hospital). There is no “Triage to Home” which is what we really need (and not just in the Emergency Department but in the whole medical profession), that is, a designation for a patient who has been quickly assessed by a skilled nurse, a PA, or even the Emergency Physician making waiting room rounds to not be sick enough for a full work-up and diagnosis. Because somebody pays, you know. Every chronic back pain, every cold, every vague psychosomatic disorder costs money somewhere. The tab is either picked up by Medicaid (and Medicaid patients are ravenous consumers of free healthcare), Medicare, private insurance, or even on rare blue moons when lightning strikes, by the patient himself…but it is all part of the two-trillion dollars we spend every year. Even if the care is unreimbursed the cost to maintain the needed capacity is very real and paid for by everybody.

The idea that some socialized, quasi-socailized, it-ain’t-socialized-much-cause-it’s-single-payer, or any other scheme to give everyone free medical care is going to alleviate the problem is laughable. While there is currently some restraint in the system against using medical resources for minor complaints, it really only effects those who make co-pays for their medical care. If you pay nothing, there is no incentive not to crowd the doctor’s office or the Emergency Department for your free pregnancy test or your motrin. All you have to spend is your time and while our department sometimes slows to a crawl with ten hours waits, you can usually be seen in three or four hours. A long time but I have waited an hour or two to see my doctor for my annual physical (itself largely a waste of money for an otherwise healthy guy) when he is running behind. What’s another couple of hours if it’s free?

What We Have Here is a Failure to Communicate

How many cardiac workups does one person need in a year? Or how many CT scans? Because I work in the Emergency Departments of two rival hospitals I am in the unique position of getting a patient admitted for vaguely cardiac-sounding chest pain and then, as if nothing happened, seeing him at the other department often only a few days later with the same complaint and, unless he remembers me which he may not, no mention in his past medical history of his completely negative nuclear stress test and exhaustive workup. The story is the same for all manner of patients. Some, like drug seekers, attempt to game the system and make the circuit of local Emergency Rooms, shamelessly spinning a tale of woe four or five times a week. Others just don’t know any better and, despite having various deadly conditions definitively ruled-out on multiple occasions at other hospitals, are perpetually looking for the definitve second opinion, or attention, or someone to take care of them for a few days…who knows. Some people just feel bad all the time and have developed a co-dependent relationship with the hospital. They suck down many, many scarce medical dollars in redundant tests, consultations, and brief hospital stays where, in reading the discharge summary, you can sense the dictating physician trying to express his frustration without out-and-out accusing the patient of malingering. For our part, they are what we call “weak admissions,” embarrassingly weak, the kind that make you cringe to discuss with the admitting service.

Some patients, let’s say someone with a volvulous, are incredibly strong admissions. All you have to say is, “The patient definitely has a surgical abdomen, is distended, tender, guarding, and vomitting,” and the admitting surgeon will say, “Okay, I’ll be right in.” Some admissions are decent, like a 65-year-old smoker with pneumonia. You will rarely get an argument or the telephone equivalent of rolled eyes. Some admissions are weak but so routine that the admitting service will demur with little complaint. Some are so weak, so worthless, and such a waste of money that I cringe to hear the voice on the other end of the line, rippling with sarcasm, saying, “You know we admitted him for that last week and found nothing, don’t you?”

Or worse yet, “Oh, we had to discharge him from our practice for violating his pain contract and trying to get narcotics from almost every hospital in the state.”

And you’re left holding the bag, playing a game of legal chicken. The patients may cry wolf but there is going to be a real wolf someday and, like a game of hot potato, nobody wants to be holding the spud when the music stops. I have a patient like this, a serial abuser of Emergency Services whose hospital tab must run in the millions, who came in one day in her usual excruciating pain but which this time was not relieved by her customary dose of narcotics and who turned out to have a perforated colon.

There are two salient points here. The first is that the medical profession does a poor job of coordinating information. It almost makes one wish for a standard, nation-wide electronic medical record accessible by every physician and made mandatory for everyone. In this manner, every prescription, test, study, and discharge summary could be pulled up and viewed by any doctor. The second point is that what we need isn’t a Good Samaritan clause (protecting physicians who offer free care) but a “Wolf Clause” to set an upper limit on the amount of work-ups and Emergency Department visits allowed for one patient. I have a 22-year-old patient, an otherwise healthy young woman, who has been to our department thirty times in the last year, been hospitalized a few times, been worked-up redundantly at both of our big hospitals, and there is nothing physically wrong with her. But she is a spud, and since I’d rather spend your money than risk my livelyhood, we take her seriously every time we see her. We may joke about it and roll our eyes but we don’t dare put our money where our mouths are.

What’s Albania Got to Do With It?

Nothing, really. Except that the Albanians don’t have anywhere near the access to high-tech health care that our citizens enjoy. Like the Greeks and many other Europeans, even their sickest patients are not typically on a long list of medications. There is nothing like our buzzing Emergency Medical hives in Albania where every Albanian who is not feeling well can get relatively instant access to almost every labratory test, imaging study, and specialist known to the medical profession. In Albania, much of what we consider the standard of care is unheard of and reserved for those who can pay for it up front. You certainly will not have your terminal illness interupted by too many of the heroic measures which are routine in our country, even for the poor. People grow old, get sick, and die almost as they have been doing since my ancestors regularly invaded and enslaved theirs.

Ah, Albania! Tarnished Jewel of the Balkans! Despite no medical care to speak of you live as long as we do and even give the perfidious French a run for their money. What does that say about how we spend money? I am pefectly willing to concede that there are quality of life issues at play. Certainly I’m glad that I may one day get an artificial knee if mine should ever wear out. And I also concede willingly that if I were critically ill, I’d be immensely glad to be in Pocatello, Idaho and not Tirana. But I’d like to humbly put forth the notion that most of the money spent on medical care in the United States and Europe is spent on the margins, which is not to say that people don’t want it and don’t demand it, but only that it is spent in large amounts with very little to show for it. Maybe past a couple of thousand a year we’re just pissing in the wind. And maybe what we need to do is to start doing less for most patients, most of time, reserving our big guns for worthy targets and not for killing gnats.

Freeloader Mothership

(Let us delve, oh my long-suffering and indulgent readers, into the realm of real economics, an area of study much neglected in the utopian groves of academe. It’s almost as if our isolated professariat, protected behind the great bulwark of tenure as they are, have become afraid to get their hands a little dirty discussing economics in any but the emotionally satisfying but ridiculous terms of various strengths and and flavors of marxism. -PB)

Can’t Fight Human Nature

The bottom line is this: We are, most of us, potential freeloaders and it is only fear of the wolves prowling outside the door that keeps us working as hard as we do. For my part, if I could find a job that paid as well as Emergency Medicine but required less work, I’d jump on it like a bum on a quarter. It’s not that I don’t like my job because I do. It’s just that taken as a whole, the fun only outweighs the crappiness of much of it if we put a decent salary in the scales. Two hundred thousand a year? A great job but not perfect. Thirty thousand? I’m not getting paid enough to do this shit. In this the Hamburger flipper and I are kindred spirits. We have to ask ourselves every day and every shift if it’s going to be worth it. The burger flipper however, has less to lose by falling into the bosom of the state and having all of his needs provided for by someone else. That’s why disability is so appealing to many of my patients but not to me. The crappy monthly subsidy they would receive as well as the modest benefits allowed by our welfare Social Justice system are not too much less than many of them could achieve on their own with the effort they are willing to expend. Some are just lazy, some sincerely believe that they are incapable of upward mobility, and some are categorically unable to breath and chew at the same time but for whatever reason, work has no appeal quite like leisure supported by somebody else, especially the modest leisure ambitions of the poor and lower middle class which involve, short of winning the lottery, fishing, hunting, eating, watching television, booze, weed, sports, and the other simple pleasures of life. Three week vacation to Italy? Not even on the radar screen. The key concept here is that every one of us has a price at which he will eschew work, or at least work that we must do to live and not a hobby masquerading as a job.

So you see, cradle-to-grave welfare Social Justice of which free medical care is only the first step wouldn’t work for me at the price the nanny state is offering. But that’s the seductive appeal of the European model for people who are not willing or able to make much more than what the nanny-state promises. The huddled masses yearning for the secure bosom of the mammary-government will give up the freedom to enjoy the fruits of their own labor to eat somebody else’s fruit. The problem is that we’re never as frugal with somebody else’s fruit as we are with our own so the natural progression in the self-fulfilling prophecy that is socialism (a word from which even socialists now run screaming), dictated as it is by immutable human nature, is an easy progression from a sense of gratitude to entitlement and then to demands for even more of somebody elses’s fruit. Eventually the ante is upped enough where even productive citizens would be crazy not to take their share of the fruit. People are lazy, not stupid.

Providing the fruit however only works as long as there are enough suckers to pay taxes. Eventually the tax burden, especially in a progressive tax system, makes the economic incentive to expand your little corner of the economy, creating the goods and services that are the wealth of any nation, next to nothing. If I am taxed at 90 percent for any income I make over a certain amount allowed by Your Sweet Lord, the Gubmint,’ the extra money I make for seeing a few more patients or working an extra shift is minimal and not worth getting out of bed except that I can go fishing instead. Your desire to see a doctor, in fact the heart-rending pleas of the baby-boomer hordes about to descend locust-like on the medical care crops will fall on deaf ears. No economic incentive, no production. The money for free medical care, not to mention for every other new right discovered by the Trailer-Park-Ghetto-Academia Axis, has to come from somewhere and it will come from increased taxation. In due time, this excessive taxation will have a deleterious effect on the ability of the productive sector, the little understood, much maligned engine that produces of all the little things in life you enjoy, to continue to create the wealth necessary to make everything free.

Many years ago I worked for a Wood Products company that was considering buying a plywood mill in the former Soviet Union. They quickly dropped the idea because after seventy years of communism (socialism’s retarded cousin) the mill was like most factories in the Soviet Union; a bloated, inefficient, poorly-run concern employing mobs of redundant, low-payed workers making a shoddy product that you couldn’t give away in the West. This particular mill made a third as much plywood with a thousand employees as a typical American mill can make with only fifty. And it was plywood of incredibly poor quality, stuff that even the most dishonest contractor would reject out of hand, and they wasted prodigious amounts of wood doing it.

A typical American plywood mill has one modern computer-controlled lathe that can peel a log down to about the diameter of a broomstick. Veneer, the strip of wood coming off a spinning log and what makes the layers of plywood, is money. The more veneer you get from a log the more plywood you can make at a lower cost. The ex-Soviet mill had five nineteen-seventies era lathes, most of which were broken at any given time, that could only peel a block (a log) to about eight inches in diameter. This valuable piece of the tree was then chipped and used to fire the boilers. American mills occasionally produce large peeler cores but only if the price of dimension lumber (e.g., two-by-fours) that can be sawn from the cores exceeds the value of the veneer. We certainly don’t burn money as hog fuel.

Theoretically the Russian mill was a progressive factory. No one could be fired and everybody had all the benefits that could be offered by the Motherland in that now forgotten dark freeloader empire. But they made crappy plywood that no one would buy unless they were forced which is the modus operandi in a command economy. Most of the workers stood around doing nothing for most of the day, absenteesim was high (but irrelevant if you see my point) and when the time came to pay the piper, the plant (and the whole country) had no value and could not honor its obligation to ensure a worker’s paradise built on the equitable distribution of goods and services by a central committee. Folks, they were selling the mill. And they were desperate to sell it which is not exactly a ringing endorsement of the progressive principles upon which the factory (or the empire) was run. Without incentive, and surely their was no incentive at this plant to even show up much less do quality work, there is no possibility of progress. A factory, and a society, cannot support a mob of time-servers and malingerers for more than a generation or two, particularly in the face of external pressure from more advanced societies, that is, ones that are maybe less “progressive” but more entrepreneurial.

Now consider another large socialist state, General Motors, which at one time I understand used to manufacture automobiles but now is primarily concerned with supporting a large dependency class and for who the production of automobiles is merely a sideline. The unions to which GM is a prisoner, with the best of intentions but now obvious short-sightedness, have contributed mightily to running the company into the ground. For many years, when times were good and Japanese cars were rinky-dink pieces of junk, the management of GM could afford to cave to union demands offering lavish benefits to its employees. People were still buying and the costs could be distributed into the high volume of increasingly poor-quality automobiles being built by employees who slowly, oh so slowly, began to resemble their more progressive comrades in various worker’s paradises around the globe.

Now, the high quality automobiles are being built in Alabama and South Carolina in mostly non-union shops. The benefits aren’t as good but the jobs are there and sustainable for an industry where competition is fierce and an extra thousand bucks per car for benefits to people who haven’t actually worked for the company in forty years makes all the difference. The ripple effects of this kind of sustainable enterprise spread throughout the South. Birmingham, Alabama is a thriving, growing city. Flint, Michigan, once the center of the American automobile industry, is a crime-ridden ghost town for which the joke among real estate agents is that they will cure AIDS before you can sell a house in that depressed market.

Not to mention that the pressure from wages and benefits has forced both Mercedes-Benz and General Motors to invest heavily in automation, technology who’s purpose is to reduce payrolls and expensive employees.

Is this fair? Not the right question because fair’s got nothing to do with it. Since we were talking about plywood mills, I’ll have you know that one of the last non-automated steps of its production occurs on what is known as the “lay-up” line where, for fifteen bucks an hour (good wages in my rural Lousiana Parish), workers fit irregularly shaped shards of veneer (“core”) between two moving ribbons of continuous veneer (“face”) before the entire assembly moves to the press. (Come on, you guys have looked at a sheet of plywood, right?) The person who invents a practical automated lay-up line can patent it and be set for life because the competitive edge provided to Georgia Pacific of not paying those salaries will let them eat their competitors for lunch…until everybody gets an automated lay-up line and then everybody can coexist in a state of uneasy parity until the next breakthrough.

And yet, despite the drive to shed jobs, the result is not a nation of jobless ex-plywood workers clogging the soup kitchens. Progress may be heartless but the net effect, the increase in the material prosperity of a nation by increasingly efficient production of valuable things (either goods or services) spurs new growth in sectors of the economy that the aparatchik running the Soviet Plywood mill couldn’t even imagine. Even in the Wood Products industry for example, although the low-wage menial jobs are almost gone, there is an ever growing demand for someone, anyone, who knows his way around Programmable Logic Controllers, the computerized nervous system of a high tech factory.

Finally, let us consider the United States, one of the largest economies in the world and whose business should be business, not attempting to directly provide for all of the needs of its citizens. We don’t even need government programs to encourage work or even to discourage freeloading. People will find their own way but only provided that there is an incentive to keep the wolf from the door. An economy that diverts large portions of its scarce resources to not only support but encourage the non-productive is not a viable concern for too long; the length of time the ponzi scheme can continue depending of on the momentum you have going into it as well as the willingness of lenders to extend credit. But you can’t support a growing number of eaters on a finite pie. The pie has to get bigger or everybody gets a progressively smaller piece. One day the shieks of Araby and the Mandarins of China will decide that supporting your demented granny’s right to that free fourth heart cath is not a good credit risk and then we’re all screwed.

So sorry.

Freeloader Nirvana

No Cows Were Harmed

Your typical leftist, a person conditioned for shameless abasement to every social issue that can be blamed on his distant ancestor who allegedly once shot an indian, eats his bowl of Ben and Jerry’s ice cream with the same gusto he usually reserves for giving other people’s money away in the name of social justice. Ben and Jerry’s, as anyone who has taken the tour-cum-political-indoctrination-session of their environmentally friendly facility in Vermont knows, makes ice cream with a social conscience (sort of Cirque du Soleil meets Baskin-Robbins) and there is no hint of filthy lucre or consumerism allowed in this happy, shiny place, even the kind that paradoxically allows people who would otherwise deny to the very gender-neutral and non-denominational heavens their involvement with materialism to spend five bucks for a high quality confection that is the very essence of unfettered materialism. It’s like paying four dollars for a coffee at Starbucks while writing poetry about lynching Dick Cheney and other evil capitalistic tools. There’s kind of a disconnect. But you see, Ben and Jerry’s is materialism with an alibi. You can feel good eating it knowing that the cows making the milk not only were given no growth hormones but also had full access to all of their reproductive options.

In a similar manner, Social Justice is just welfare with an alibi and is a concept to which the left has cleaved because “welfare,” itself at one time a noble sounding word, has so many justifiably negative connotations that to but breathe your support of it will lose you an election faster than a fat kid can inhale a cupcake. The very word itself carries with it the image of a great mass of freeloaders, relieved from the responsibility of providing for themselves, deciding to trade the struggle for a possibly higher standard of living for a lower one but one which requires no productive effort on their part. An unfair generalization of the poor, but true enough in many particulars for anyone who understands human nature and the destructive effects of a large dependency class on both the the intangible moral fiber of the nation as well as the on the economic growth required to pay the tab for multiplying entitlements. The number one problem, after all, of all the Western Democracies is paying for the freebies that were rashly promised in the deceptive times before people discovered that being non-productive was a viable option.

Without belaboring the obvious (although maybe not so obvious as economics seems to be little taught nowadays in the propaganda mills that pass for universities) a government has three choices open to it to pay for its obligations; things like Medicare, for example, which is an obligation because it promises, by law, to pay for the medical care of the elderly even if and when expenditures outpace the tax revenue required to meet the obligation. Your elected representatives can either borrow money from the private sector and do nothing (always a popular choice) in the hopes that the system will only crash and burn after they are out of office; they can print or otherwise create funny money to throw at the problem resulting in inflation and a comensurate devaluation of the currency; or they can raise taxes, a strategy with tremendous appeal to the purveyors of class envy but which has disasterous consequences on the production of goods and services, stifling as it does the incentive for individuals to be productive and increase the wealth of the nation. This wealth is the sum total of all the goods and services produced and what is required to to serve as collateral for the mortgage we sign when give every American the right to have as many babies as they want on somebody else’s dime or take no responsibility at all for any aspect of their medical care.

And we’re going to justify this kind of thing by invoking Social Justice, a nebulous phrase that is so ghost-like nobody can really define what it means except that by God, somebody’s giving out free money! To some, social justice means equality although it’s a crazy kind of equality. If everybody is equal and medical care is a right, are people who pay for better medical care violating somebody else’s rights? This would make the entire ruling classes of Canada and Europe, people who can and do avail themselves of medical treatment not available to the proles, the biggest violators of human rights on the planet. They need to be arrested. But why stop at medical care? Housing is more important to most people. You’ll die in an hour or two here in the frozen part of Yankeeland without shelter. Your high blood pressure? Hell, that’ll kill you at a leisurely pace. Does the right to housing guarantee a yurt? A crappy apartment in some crime-infested project? A split-level ranch in the suburbs? A mansion? Why the disparity? It is a right after all. My freedom of speech is not better than anybody else’s, why is the right to housing any different?

Some leftists, driven by self-loathing for their privileged upbringing and their hatred for their nation, define Social Justice as payback, extortion to be paid to the poor because once upon a time, some African tribal king sold a distant ancestor of the underserved to a Muslim slave trader who ended up, after being processed in a Portugese baracoon, in the Virgina colonies. The only equitable thing thing to do then, if you go in for this kind of nonsense, is to give everybody who still feels the psychic pangs of the suffering of their distant ancestors a bunch of freebies, paid for by people whose ancestors may have had nothing to do with the distant crimes and in fact, as is the case of my own Greek ancestors, had their own problems at the time. In the name of equality and Social Justice, we’re going to assign collective guilt to people based on nothing but their ability to pay protection money to their leftist masters, a strange notion of justice more in keeping with some third-world kleptocracy than a country built on the principles of individual freedom and inalienable rights.

Throw then, oh you who long for social justice, a general blanket of oppression over everybody who is poor and insist that it is The Man keeping them down despite the fact that a constant stream of immigrants, arriving from countries were oppression truly exists, have somehow managed to pull themselves out of poverty and run circles around the children of the big, bad oppressors, those rough beasts, their hour gone, shuffling towards the trailer parks. It will have to be a general kind of blanket, a big, wet, suffocating blanket because unless you plan on convening a Council of Wizards to divine the complicated mileu of each life-perhaps deciding that a Greek who only suffered a little at the hands of his ancestral oppressors is only equivalent to three-fifths of a real, oppressed man in good standing-there is no way to equitably distribute anything at all. To even try is to exacerbate what isn’t even a problem except that we gotta’ have our alibi.

Freeloader Heaven

Screw Social Justice

If you proposed to me that all of the poor were lazy and desired nothing more than to live lives of sloth and overindulgence; smoking their cigarettes, drinking their cheap booze, shooting their drugs, and having their lllegitimate babies willy-nilly at the taxpayer’s expense I would call you a starry-eyed idealist and and someone without a firm footing in the real world. In no way would I want your naive idealism to guide public policy because your point of view would be so extreme as to be ridiculous. And yet if you were to propose the converse, that the poor were all noble creatures mightily striving but failing to obtain their slice of prosperity because they were held back by racism, inequality,and every barrier that could be put in their path by The Man, you would be feted as a deep thinker, a person with a firm grasp on reality, and your own peculiar brand of idealism, as equally ridiculous, would inform a hundred public policy initiatives.

But that’s the problem with Social Justice, especially as it is used to justify giving everyone free health care. It makes the assumption that everyone is a victim and doesn’t allow for the possibility of the freeloader who not only exists in droves but is aggressively selected for in every nanny-state ever created. People may be lazy but they aren’t stupid and, as most people do not love their jobs, if the conditions are set to obviate the need for work many people will tend to do as little work as they possibly can. This sort of society is not sustainable for more than a generation or two as our cousins in Europe are starting to realize and it is certainly going to bankrupt our nation if we continue down the same path. In fact, the number one problem in all of the Western Democracies boils down to the unsustainable growth of entitlements paid to non-productive citizens by a dwindling pool of productive workers. Many of the recent riots in France, for example, were instigated by their government’s clumsy attempts to slightly reduce entitlements, already at levels that would make our most flagrant abusers of the welfare system blush with shame.

With this in mind, you’d think that our goal as a nation would be to reduce entitlement spending, limiting it as much as possible to those hopeless cases who demonstrate that they would actually starve to death or die from lack of primary care if not given a helping hand, not to work towards the opposite goal of giving everyone free everything whether they need it or not. Not that anything is really free. The money comes from somewhere although governments occasionally take leave of their senses and print money with nothing to support it, a short term strategy that fools nobody and leads to inflation and lack of confidence in the currency.

Unfortunately the mob, once it discovers it can vote itself access to other people’s wallets, is difficult to keep in check and the usual dependency triumvirate of ghetto, trailer park, and academia are perpetually braying for somebody else’s money. The extent to which this money can be secured depends on how many productive citizens can be lured onto the dependency plantation, usually by the propaganda of fear and class envy. The problem with creating a welfare state is that it tends to fulfill the dire prophecies of its creators. The more productive citizens are taxed the more economic activity is stifled leading to stagnant economies where there are, in fact, no jobs for many people who would be employed if growth and economic opportunity were encouraged at the expense of stealing from one set of citizens to give to another.

Social Justice is a euphemism for welfare, a word that has been so thoroughly demonized that the left has to invent a more pleasant sounding phrase.

Make Up Your Minds

The usual suspects crying for social justice are deeply conflicted anyway and their outrage is mighty selective. On one hand they argue that a collectivist approach needs to be taken to distribute medical care, essentially saying that doctors and nurses who provide this care should be forced to provide it at whatever price the the congress, acting entirely from self interest, determines to be fair. And provide it even if it entails the majority, through increased taxation, sacrifice some of their material prosperity the use of which for their own purposes is the ultimate freedom. On the other hand if I insisted that for the collective good, the ability of a citizen to sue his doctor be severely curtailed, the usual suspects will wax sanctimonious about the inability of a free people to allow even the smallest of their rights to be violated at any time, in this case the right win a legal jackpot.

Surely some medical lawsuits have merit but under the theory of social justice, for the collective good of the majority who would benefit from cheaper medical care, the minority deserving of malpractice awards would have to suck it up for the greater good. Likewise, if I insisted that for the collective good we put yer’ elderly granny down when she becomes too much of a burden to the nanny state the cries of outrage would ascend to the very heavens.

As if we don’t have enough trouble administering real justice we now have to gear up to dispense social justice, a highly nebulous concept the implementation of which requires that grievance, race, age, social status, intelligence, and other things that Americans should ignore be worked into an arbitrary and impossible behavioral calculus to give to each according to his need and to take from each according to his ability.

Throwing Money Away and other Medical Topics

(I confess, what with the feasting, shopping, caroling, and wassailing of the holidays I cannot collect my thoughts to write anything coherent longer than a couple of paragraphs. My apologies. -PB)

Taking Leave of our Common Sense

In a previous article I mentioned that politically, health care reform was not a big issue for me and I was instead more concerned about national defense and killing terrorists. I reiterate that from a purely utilitarian point of view, building, equipping, and manning a Carrier Battle Group is a better way to spend our national treasure than attempting to guarantee free health care for all. I know that as physicians we’re supposed to believe in medical care like foxes believe in chickens but there are more important things in life most of the time, for most people, most of whom don’t need that much medical care except on infrequent occasions. It is more the fear of not getting medical care that is driving the current electoral panic rather than any real risk that anbody is going to be left outside the door of the hospital for lack of insurance. While it is true that there is a small subset of the population who have no medical insurance, this doesn’t mean that the majority of them have no access. We act as if access can only be had if somebody else pays the bill but large numbers of the uninsured could afford major medical insurance and their own primary care (which is not expensive) except that they have other priorities. There is nothing preventing their access to medical care except their reluctance to divert money from other, more important discretionary spending.

That and a lack of primary care physicians but that’s not a problem that can be solved by giving everybody free health care. Even the insured have difficulty finding a doctor and waving a magic wand, declaring that the unwashed now have access, and even throwing a bunch of money at the problem is not going to materialize a couple hundred thousand primary care physicians out of nowhere.

The real question is whether somebody who doesn’t care about their health should get free health care courtesy of the public treasury. A pack of cigarettes costs around five bucks in my neck of the woods. That’s 150 bucks a month, to which we can add another couple hundred for booze and other irregular pleasures. With this kind of money changing hands even among the Holy Underserved, it is inexplicable why you or I should be asked to finance their routine health care except through some sort of quasi-extortion where the usual suspects pushing We-Swear-It’s-Not-Socialized-Medicine hold a gun to the patient’s head and threaten us with higher costs down the road if we don’t cough up some money now. Or look at it like a mugging where, to avoid getting hurt, we’re supposed to hand over our wallet without making any trouble.

The key concept is that primary care is not expensive and, under the care of a physician who has the time to think about a patient, it can be extremely effective in keeping chronic conditions stable or at least delaying the inevitable expensive interventions significantly. But only if the patients give a crap about their health which no amount of free health care will do a thing to encourage. In other words, a good predictor of how much or little expensive medical care you will eventually need during your life is the amount you care about your own health. If you care, you will pay for the occasional doctor visit even if you have no insurance and both take your medications (which are hopefully inexpensive generics) as well as take steps to modify your lifestyle. If you don’t care then you will ignore your doctor, decide that personal watercraft are more important than your blood pressure medication, and despite getting all the free primary care in the world you will still end up dying the death of a thousand interventions as you decompose slowly in the medical triangle trade. (Nursing home to Emergency Department to Intensive Care Unit.)

To smoke a pack a day in the face of severe emphysema or to choose booze over your antibiotics is to demonstrate that you don’t give a rat’s ass about your health. If you don’t, why should anybody else except because of the previously mentioned blackmail mentality?

Throwing Money Away

Primary care is dying in this country, largely because the the government which sets both the amount that doctors are reimbursed for their time as well as pattern by which private insurance reimburses, has decided that cognitive skills are less valuable than throwing a lot of procedures at the patient. Most of this is a lack of trust by parsimonious bureaucrats who reflect the general American character trait of preferring action to deliberation. A typical patient, if he gets a large bill from an internist who did nothing but ask a lot of questions, poke him a little bit, and then lean back in his chair staring at the ceiling while he thought about the case, feels as if he’s been cheated. After all, he spent an hour with the guy and he didn’t do a thing but change his medications a little and give him some advice.

The motherfucker didn’t even order any tests.

On the other hand if he presents to the Emergency Department and is loaded to the gills with intravenous contrast dye and then assaulted with every possible test and invasive procedure imaginable, the typical patient or his family will settle complacently into their happy zone convinced that now, finally, they are getting their money’s worth. Doesn’t matter that much of what is done is unnecessary or at least could have been replaced with a little bit of sound clinical judgement, nobody’s happy until they see some action.

This is not to say that people don’t want to spend a lot of time with their doctor, just that they don’t feel they should have to pay more than a couple of bucks for the privilege. Thinking is easy, after all. It’s not like the doctor had to do anything. The government has picked up on this philosophy and has subsequently come up with the perfect formula to save money which, as is typical when people who are qualified for nothing else but government come up with a plan, has resulted in large amounts of money being thrown away.

Consider the typical internist or family physician trying to keep the lights on in his practice. The amount that Medicare or Medicaid (and private insurance as they typically take their reimbursement guidance from the government) pays the doctor for his cognitive skills; the traditional history, physical exam, and clinical judgment, is so small in relation to both his expenses and his completely reasonable desire to make as least as much as a decent auto mechanic that he is forced to run a high volume practice. Of course, not every patient requires a long visit and certainly a more complicated patient can be given a little more time but when you are seeing thirty patients a day, you can see that it is impossible to give the truly sick and the multiply co-morbid the time that they need.

The typical elderly patient who needs anything more than a routine physical exam cannot have her problems addressed in a fifteen minute visit, much of which is taken up by compliance and admininistrative tasks. Consequently, there is a disturbing tendency to consult specialists for every medical problem that will take more than fifteen minutes to address (a tendency that is completely separate from the legal imperative to fend off the predatory plaintiff’s attorneys). The result of this is that you have three or four doctors doing the work that one could do with all of the lost time and inefficiency that this entails. Additionally, under the theory that to the man with a hammer everything is a nail, when you send a patient to a specialist they are going to use their signature procedures to the full extent allowed by reimbursment and ethics. In other words, the default position of a gastroenterologist is to perform the colonoscopy because short of this, he may be adding nothing of value to the patient’s care. Now, I’m not saying that there is no use for specialists, just that sending a patient to a specialist to confirm something you already know or to implement a treatment plan that you would start yourself is a waste of money…except that the economic realities of primary care make it impossible not to use them like this.

Many specialists are used as nothing more than physician extenders, kind of like mid-level providers if you think about it, for busy primary care physicians who know what to do but don’t have the time.

The Ticking Time Bomb

Having patients followed on a routine basis by a cadre of specialists is not only wasteful but dangerous. Under the team-based health care delivery philosophy, physicians are supposed to communicate with each other but, as talking to other doctors is generally non-reimbursable time, communication suffers for the same reason every other poorly-reimbursed activity suffers. The danger is that patients who are being followed by a disorganized squad of specialists will receive dangerous interventions and studies seemingly willy-nilly and, most importantly, are placed on long lists of medications, the interactions of which cannot possibly be fathomed except that someone has the time to sit down and spend an expensive half hour doing it. I regularly see patients with one-page medication lists taking three or four medications of the same class as well as medications that seemingly act at cross-purposes, not to mention having the potential for dangerous interactions.

I know perfectly well that many patients require this kind of complexity but after you see enough unexplainable altered mental status, coumadin levels (INR, I mean) through the roof, as well as the effects of everybody’s favorite loaded gun, digoxin, you sometimes wonder if anybody has ever taken the time to verify that yer’ demented granny really needs to be on 20 different pills.

Now, and I’m just thinking out loud here, what cardioprotective effects are we getting by keeping an 89-year-old woman on a beta-blocker, a statin, and an ACE inhibitor that are not completely offset by the possibility of side-effects and dangerous interactions with her other medications? It is this and other questions that need to be addressed and decisively answered by one doctor who has the time, via adequate reimbursement, to do it. The alternative is highly fragmented and slipshod care.

And no, it is not enough to expect the patient to keep track of these things. Some can of course, but it is very common for the multiply comorbid patient to know nothing more about his medications than their colors and shapes or that one is a water pill and another is for his “gouch.” In an ideal world, the only variable would be the compliance of the patient, not the confusion that results from trying to coordinate the care of various specialists.

Happy New Year

Another one has come and gone. One day, as the memory of medical school and residency fades and I have to devote most of my free time to moonlighting at Taco Bell to make ends meet under whatever silly health care reform comes out of the trailer parks, ghettos, universities, and other islands of provinciality and entitlement in America, I may grow tired of this blog. As I am, however, still going strong, I appreciate your taking the time to spend your time reading and I hope I can continue to provide you with a good reason for doing it. As always I appreciate all comments even the ones I have to delete.

Hey, we have rules on this blog. I had to go to a moderated comment format because of a few people with bad manners and I hope this hasn’t been too much of a burden. Not to mention that my spam filter catches about a thousand spam comments a day which leads me to this question: What on earth has Britney Spears done to deserve this kind of attention? Fully half of all the spam comments I receive promise to link me to naked pictures of her in all kinds of situations. I’m just not that interested. In fact, my interest in Paris Hilton, Anna Nichole Smith, and Anglina Jolie, the other members of the internet Gang of Four, is about a 0.001 on the ten-point pain scale.

Putting Granny Down and Other Health Care Conundrums

(I hesitate to present this article because everything in it is so indisputable to those who work in health care that I might be accused of belaboring the obvious. With this in mind I ask for the indulgence of you, oh my regular readers, who may skip this article entirely as nothing new will be covered. I submit this article in the hope that random internet passers-by, people who have no idea how health care is delivered, will find something interesting in it and that it may give them a different perspective from their usual desire to pay as little as possible for a service that they think comes as easily as turning a tap provides water. I also want to give a hat-tip to the Happy Hospitalist for his excellent series of articles laying out some of the facts of life about health care and its cost.-PB)

Bread and Circuses

This is not a political blog and I like to avoid discussing politics as much as possible for not the least of which reasons that civil debate is impossible even with many who consider themselves well-informed and open-minded. You can, for example, have what you believe to be a reasonable conversation with what you take to be a rational person when something inside them snaps and they start foaming at the mouth about the CIA plot to topple the World Trade Towers, blame the Muslims, and allow President Bush to assume dictatorial powers. This sort of thing used to be confined to the lunatic fringe but now even otherwise respectable political candidates, sensing that kookery has become more prevalent, will cater to these kinds of impulses. This is not to say that we don’t have long history of colorful politics in our country but only that we have not advanced much in our political discourse in the last 231 years. The mob gets an idea in its head, placed there or at least reinforced by its political leaders, and the thing is obliged to run its course no matter how destructive or ridiculous.

The latest idee fixe of the mob is that Health Care is a right and sensing the political winds, even some of the Republican candidates in the impending presidential election, ostensibly from a party that traditionally serves as a check to some of the more destructive initiatives coming from the left, have embraced the notion. What the left means, of course, by declaring medical care to be a right is that someone else needs to provide it regardless of the effort required. The Holy Grail of the left, after all, is the quest to have someone else take care of all of their basic human needs leaving them free to work at some meaningless public service job from which they can never be fired and which shelters them from the productive sector. (College professors, who strive mightily for tenure and the shelter from the world that it provides, perfectly epitomize the desire of many to fall into the comforting bosom of the nanny state.) As it has never been hard to convince people that things should be free, in this particular lying season the race is on to see who can give away as much of other people’s time and effort as possible. Some political candidates will be more overt taking the more obvious socialistic route while others will be more circumspect, inventing ingenious formulas to prove that we can pay for all the health care everybody needs without spending every dollar of tax revenue doing it and without comprimising any of the other legitimate functions of government. We have but to fix the health care system and everything is going to fall into place.

The premise of the health care debate is wrong, however. The health care system in this country is not broken. It is a beautifully evolved creature, functioning perfectly, and exquisitely adpated to the political, legal, and economic environment in which it operates. In other words, every initiative to fix health care wil be useless, as ineffectual as rearranging the china while the bull still rampages, unless the underlying conditions that dictate the current system are addessed and there are very few political candidates with the political courage or even the understanding of the problem to do it.

Consider first the legal environment in which we operate. It has been correctly pointed out that awarded damages and even malpractice insurance costs account for a relatively small fraction of total health care expenses. This fact is used by plaintiff’s attorneys to justify their depredation on physicians and hospitals, tacitly admitting that while they may be somewhat overzealous as they chase ambulances, their activities amount to very minor parasitism and should be ignored. It cannot be denied, however, by anyone who has been less than a quarter of a mile from a real patient that a large portion of a physician’s work, and by extension the support staff’s and the hospital’s, is devoted to keeping the lawyers at bay. What is most paperwork, after all, but an attempt to cover oneself legally against every possible bad outcome, even those that are an inevitable result of either the patient’s own incredibly bad health or equally incredible irresponsibility. On the witness stand, unfortunately, every patient is a sympathetic figure who has been harmed by an incompetent doctor from whom not only absolute perfection but absloute omniscience is expected.

It is no wonder then that much of a physician’s time is spent wrestling increasingly detailed paperwork designed to automatically protect against legal jeopardy. Little of this time has anything to do with patient care and yet oppressive paperwork is so indispensable in modern medicine that it would be no exagerration to say that most of every physician’s time is spent typing at a computer or writing notes even though it is common knowledge that from a purely medical point of view, everything pertinent about most patients most of the time could be written in big letters on one side of an index card. Who is seeing patients, the real deluge of which is looming and has yet to hit the system as the baby-boomers discover that their coronary arteries are no different from their parent’s, when the doctor is trying to devise medicolegal documentation to dissuade the lawyers?

No one. They tell me that we have a physician shortage and yet the paperwork burden on physicians keeps increasing as even the very hospitals which should be lobbying against this kind of thing invent even more complex paperwork systems to ensure that if anyone should step out of line, the trail of plausible deniability is intact and somebody else, the physician who never completed his JHACO certification in hand washing for example, is the culpable party. It is this lack of trust, this hopeless desire to avoid legal risk, that adds an incredibly expensive burden on our health care system.

In addition to the paperwork requirements, the wasteful and futile effort to prevent the legal profession from finding chinks in our professional armor, the threat of litigation forces the physician to ignore good medical practices and common sense in how health care resources are spent. There is, it seems, no complaint too trivial or no presentation of a chronic condition that does not require a physician, if he wishes to avoid placing his career and property in jeopardy, to order every test and study under the sun on a fishing expedition to avoid the possiblilty of a missed diagnosis. Thus do many patients with vague abdominal pain and unimpressive physical exam findings receive a healthy volley of testing and imaging, the exact extent of which is often dependent on how often or if the physician has ever been sued for a missed diagnosis.

The point here is that some conditions will be missed. If you want to minimize this probability, already vanishingly small just using the traditional skills of history and physical exam, it is going to cost money, a lot of money, as we are well within the realm of diminshing marginal returns and playing the zero-defect game, while it may pick up the rare silent presentation of a deadly disease, results in a huge number of expensive, low probability studies which only confirm what we already know, namely that the patient is not sick. You cannot have it both ways, on one hand opining that health care is expensive but on the other insisting that expensive technology should always trump medical judgement. The current system is adpated to allow physicians to survive both the onslaugt of the legal profession and the often unreasonable expectaions of patients who are conditioned to expect a test or a study and won’t believe a doctor unless they see the labs.

Things Cost What They Cost

I had a patient several months ago, a very pleasant, otherwise healthy middle-aged gentleman who looked fit and had obviously spent his life taking care of his health. He stated that he was an avid runner and he looked the part, several orders of magnitude fitter than most of my patients that day who were half his age. His presenting complaint was a vague, intermittant sensation of chest pressure which had started several months before and which he had been ignoring until his equally fit, highly intelligent wife had finally ordered him to come to the Emergency Department. He was without symptoms at presentation with a completely normal EKG and, other than his age, had absolutely no risk factors for coronary artery disease. As he had a very good cardiac story, we began our standard cardiac workup (that we actually do even if the story is not so good), fully expecting that all of his laboratory studies would be negative and he would be admitted for a routine exercise stress test which would probably be negative after which he would be easily discharged with the usual boiler-plate discharge instruction for chest pain of an unknown origin.

Twenty minutes after I first saw him he developed a mild, constant nagging ache in his chest which was initially relieved by subligual nitroglycerine. A repeat EKG showed what are known as ST-segment depressions (indicators of ongoing ischemia) in the lateral leads. This was followed shortly by an unequivocally positive Troponin, one of the standard cardiac markers. Clearly there was something going on and our disposition plans changed accordingly to an immediate cardiology consult for an as yet urgent (but non-emergent, you understand) coronary artery catheterization. He was definitely “ruling in” as we say.

Shortly after our call to cardiology the patient develop more severe chest pain which could only briefly be managed with a nitroglycerin drip and morphine before it became excruciating, doubling the patient over with pain and nausea. Another EKG now showed pronounced ST-segment elevations, the harbinger of ongoing myocardial infarction, in the inferior leads. The patient was now having a massive heart attack, all in the space of less than an hour from a standing start of a normal EKG and no symptoms. He was taken to the cath lab for an immediate catheterization which showed an almost complete occlusion of his entire right coronary artery, not quite as bad as an occulsion of the Left Anterior Descending Artery (also known as the widow-maker) but bad enough and certainly a life-threatening or life-ending event all the same.

He walked out of the hospital two days later “feeling great” with plans to contnue his healthy lifestyle.

Fifty years ago this gentleman would have either died in the Emergency Department or shortly thereafter. At the very least he would have left the hospital after a several week stay so debilitated that a normal life would have been impossible and probably would have continued to have heart attacks and arrythmias until one or the other finally killed him, probably fairly soon. Although he may have had an extensive hospital stay, he would not have received forty thousand dollars worth of life-saving medical interventions and the health care system would be spared the inevitable expense of the complications that would have developed as my patient aged and, despite his healthy lifestyle, reached and passed his pre-programmed genetic obsolescence.

This is one patient. A guy who is doing everything he’s supposed to and yet I have no doubt that the cost of his health care will eventually run into the millions of dollars as greater and greater efforts are made to save his life. Now consider that most of my chronically sick patients are in no way making even the slightest effort to take care of their health and, where my otherwise healthy patient had an isolated cardiac event which should be relatively easy to manage, these patients each have several to a dozen deadly medical problems which are only prevented from killing them by the expenditure of vast sums of health care dollars. Fifty years ago they would not have survived the intial heart attack or the the failure of their kidneys. Their kindly country doctor would have arrived at the house with his well-worn doctor’s bag, examined the patient, looked appropriately grave and directed the family to call their priest and the funeral home. The total cost to the health care system would have been whatever the doctor charged for his visit and the patient’s family themselves would have paid the bill.

It is therefore senseless to complain about the cost of health care and long for the fairly recent days when providing medical care did not suck up a fifth of our gross domestic product. Times have changed. Medical care today is expensive because it is a sophisticated enterprise employing some of the highest-skilled and most intelligent people in our society. Fifty years ago, while doctors were equally intelligent and trained to be superlative diagnosticians, the treatment options for serious medical conditions were severely limited and the deteriorating course of a cancer patient, for example, was followed more for the intellectual exercise than for the ability to intervene. There was no Golden Age of medicine when doctors were more caring and provided effective and economical treatments. Doctors may have been more caring fifty years ago but thats’ all they had to offer. It was just play-acting which is not very expensive.

You then, who complain about the cost of medical care should look to yourselves and your own families. Keeping your aged grandmother alive is expensive. The majority of all health care expenditures for a typical pateint are incurred towards the end of their life. As their medical problems accumulate their care becomes a constant battle, waged with expensive specialists and procedures, to briefly stave off the inevitable and ends up costing the health care system thousands of dollars for every month added to the life of the elderly and multiply comorbid. Whether this is a good or a bad use of resources is the subject for another debate. But you can’t have it both ways, on one hand expecting that no expense will be spared squeezing the last dregs of life out of you and your family while at the same time acting shocked, yes shocked, that your health insurance premiums are so high. As the Happy Hospitalist notes, you can’t insure a burning house. The amount of money required to keep your aged gandmother alive at the twiglight of her life far exceeds any health insurance premiums, either to private insurance of Medicare, that she has paid in her life. The money has to come from somewhere. To demand that expenses be reduced is the same as asking that care be withdrawn from somebody else’s grandmother, something that sounds reasonable as long as it is done to somebody else.

Throwing Good Money After Bad

I see the same patient, it seems, several times a day: An octogenerian, severely demented nursing home resident who spends their day laying in their own feces and urine except when they are sent to the Emergency Department by the nervous staff for an exacerabation of one of their many comorbidities. The EMS report usually states that the patient, a person who has not stood upright or talked to anyone since the Clinton administration, has had an alteration in their mental status, a brief interval of decreased oxygen saturation in the setting of severe emphysema, or an irregular heart rate which did not resove under the automatic ministrations of their second Automated Implantable Cardioverter Defibrillator. They are usually found to be septic from one source or another and are often admitted to the ICU for a week or two of highly expensive critical care to stabilize them enough so they may be returned to their warehouse until the next time. This little drama is repeated many times until finally we reach the limit of our ability to cheat the reaper and the patient finally dies in the ICU, usually after one more round of expensive interventions demanded by the family who want no expense spared in the effort to squeeze out one more week of life for the patient..

For perspective, maintaining an ICU bed costs a hospital several thousand dollars per day which someone, somehow, has to pay. Medicare and insurance companies can low-ball doctors with impunity but as the cost of a physician’s services are a relatively small portion of the total cost of running the ICU, an enterprise that involves many highly trained nurses and the latest equipment, there is no way to realistically decrease the expense of taking care of a critical patient.

My European friends, some of them physicians, are amazed at the measures we take to keep patients alive who have absoutely no quality of life and no chance of recovery. The Europeans may have cradle-to-grave socialism but they have a fairly well-defined idea of when to let the patient go to their grave. In the United States it seems sometimes that we want to follow the patient into the mausoleum, trying to the very last to get one more day or even one more hour of life for the patient regardless of cost. This is a mindset that is built into our system, evolving as it has from the egalitarian and extremely misguided notion that the patient or their family should be an equal partner in medical decision making. I say misguided because putting the patient or their family in charge of health care without at the same time making them responsible for their decisions is a formula guaranteed to lead to excessive spending. It is easy to say, “We want everything done,” if someone else is footing the bill. If we but required families of terminally ill patients for whom all care is futile to pay even a fraction of the cost for their care there would be a mad scramble for the proverbial plug.

Whether it is good or bad that patient’s families have so much say in the decision to continue futile care is also the subject for another debate. But as long as there is no disincentive for the families and no ability for the physician to finally throw in the towel, our system is going to be ridiculously expensive at the terminal end and there is no way this will ever change until a political candidate has the guts to say, clearly, that to save money it may be necessary to put your granny down.

Screw Cuba, How About Them Albanians? (And Other Musings)

One More Time…

Let me try to explain this again. American medical care is expensive for everyone because the costs are shifted from one set of consumers to another. Most of us are not sick and except for the odd hospitalization for something unexpected don’t really require that much doctoring. There is, however, a small but significant subset of the population who use a terrifically disproportionate amount of health care. I write about this group extensively on my blog and they include the living dead vegetating in pre-death staging areas nursing homes, the multiply comorbid, and people who make bad lifestyle choices resulting in a state of perpetual symbiosis with the local hospital. Upon this group of people is brought to bear the full might of our technologically sophisticated but extremely expensive medical arsenal.

I treated a 79-year-old man the other day who has, I kid you not, eight stents in his coronary arteries, a history of three pulmonary emoblisms (emboli?), a greenfield fiter in his unamputated leg, diabetes, peripheral vascular disease, renal failure, a colostomy, a PEG tube, senile dementia, emphysema, and a string of minor strokes before the Big One that knocked out what looked like the entire left hemisphere of his brain. I have no doubt that the cost of his health care just in the last few years would be enough to pay for the health insurance of an entire Cuban province and probably runs into the millions of dollars, not one cent of which he or his family have paid or even expect to pay because you are picking up the tab with your outrageous health insurance premiums and twenty-dollar aspirins. Maintaining an ICU bed, for example, costs a typical hospital several thousand dollars a day and this gentlemen has spent months in the ICU while his family urges us to keep his heart beating regardless of the cost.
In Europe, this patient would have died fifteen years ago, probably after his first heart attack. Maybe he would have gotten the first heart catheterization, maybe he wouldn’t, but as his comorbidities snowballed the Freeloader Kingdoms would have cut their losses and, while advanced treatments are theoretically available, the reality of rationed care would have finished him off. A Greek doctor of my acquaintance related to me that even what we consider routine critical care would be considered extremely heroic and almost unheard of over there.
The argument goes that if this poor son of a bitch only had access to good primary care he wouldn’t have found himself in these dire straits requiring this level of care. Putting aside the obvious fact that many such patients in the United States have had excellent access to primary care (many of my ICU patients are retired from GM), and the dubious belief that primary care will keep people from cramming the metaphorical pie into their notional gob-holes, let’s asume that cheap primary care would have made this guy well and allowed him to live comfortably and productively into his golden years requiring nothing but a couple of inexpensive pills and a few doctor’s visits to manage relatively benign complications of his well-controlled medical problems. If this is the case and if all that is required to make the United States a Cuban-style health care paradise is cheap primary care, why should the government have to pay for it at all? In other words, if it’s cheap, why can’t people buy it themselves? A doctor’s visit here or there and a few pills probably costs less than most people spend on cable television. I know for a fact that one of my frequent patients can afford a thirty dollar a day marijuana habit (but won’t scrape together a couple of bucks for antibiotics at the local Wal Mart which practically gives away a long list of generic drugs) so a couple hundred a year for his doctor visits is a trivial amount.

Primary care is cheap. It’s so cheap that it makes no sense giving it away for free, particularly when to give it away is going to require the massive bureacracy typical of all government solutions, a bureacracy that will inevitably stifle everything that is good about American medicine and turn us into just another society with excellent access to health care unless you really get sick at which point it is hasta la vista, baby. For the sake of your fear of cutting into your blunt money, you are willing to turn over close to twenty percent of the economy to people whose only talent is that they have no talent for anything but government.
Still, nothing is really going to change. All we’ll be doing is throwing bad money before good because while a small percentage of patients who are destined for the comorbidity jackpot may have a come to Jesus moment where they decide to modify their behavior, most will continue as if nothing happened and arrive on schedule, after hitting all the expensive milestones, to thier fabulous yet terminal month in the ICU.

It’s not as if the public will actually accept rationing of care for their demented granny. Any politician who suggests that to control costs we need to put her down like a dog (so to speak) is destined to go down in flames. What is will happen is that we will continue to spend fantastic amounts of money on health care and when the numbers get too alarming, measures will be taken to control costs that, by removing the incentive for productivity, will make the problem worse.

Or Look At it Like This…

Consider the American military in comparison to the typical European military. The American military is an expensive, technologically sophisticated organization that is twenty or thirty years ahead of anything the Europeans can field. We almost can’t share the same battlefield because of the speed and sophistication of American weapons, command and control, intelligence, and logistics. The American military can do things and go places. The Europeans have difficulty doing anything including finding reasons to maintain the militaries that they have.

But the Europeans do spend less and they do get whatever it is they want from their armed forces. And yet the capability to transport a couple of Marine Regimental Combat Teams or an Army Armored Brigade anywhere in the world on short notice doesn’t come cheap, nor are carrier battle groups operated on a shoestring. You get what you pay for. A primary care military with conscripted soldiers who don’t expect to do much is fairly inexpensive and looks pretty good until you have to make it do something. A working war machine isn’t pretty and to make it do something requires the dedication of motivated troops and frightening amounts of money.

Life Expectency

With the exception of Japan, the average life expectency of every country in the developed world hovers around 80 years. The average life expectency in the United States is 78 years. In the European Union it is about 79 years. The difference is nothing to get excited about and seems to be unrelated to per capita expenditure on health care. Those cheese eating surrender monkeys (the French I mean) may be healthier than Americans but they only live, on average, a couple of years longer than we do. It may be true that they only spend half on a per capita basis what we spend on health care but perhaps past a certain point there is no relationship between life expectancy and health care expeditures. Sure, you’re screwed if you’re from Namibia (average life expectancy of 40 years) but you’d be hard pressed to make the case that we get all all that much of a bang for our bucks or that European health care is better based on a a few months difference in life expectency.
I mean, the Albanians spend next to nothing on health care (36 bucks per head per year) and they still live almost as long as the typical citizen of the European Union. How on Earth is this possible? Albania is a shit hole. The only Third World country in Europe. Do French politicians propose that the EU go to the Albanian system to save money?

Perhaps because life expectency in part depends on cultural factors which have nothing to do with the medical care, it is a poor indicator for its quality. I have travelled extensively in Europe and I have never seen anything remotely close to the five and six hundred pound behemoths that hardly raise an eyebrow in our hospital. But this is more a result of the thirty buffet-style restaurants within two miles of the place than some hard-to-define shortcoming of our health care system. I know for a fact that many of these monsters will enjoy terrific access to health care untill the day their bad heath finally catches up to them and they become a statistic dragging down our average life expectency. If you look at it this way, and factor in things like gang violence which decreases the life expectency of black men to 67 years, the premature babies who we try to save at gestational ages which would make the Europeans laugh contemptuously, and half a dozen other cultural factors which have nothing to do with health insurance it is a wonder that we live, on average, as long as we do. Apparently, for every Tupac harvested early to the Lord we have a ninety-year-old vegetable sucking life through plastic tubes bringing up our average.

Addendum: I propose the following thought experiment. I live in an average Midwest city with a population of around 200,000. Let us charter a bunch of airplanes and exchange the non-medical population of the city with the population of a similar-sized French city, say Toulon. Let us then follow the two cities for the next couple of years and see how they fare in regard to health care costs. I predict the following: We will get a much deserved vacation, working at our hospital will be a cake walk, and those poor French bastards will reap the adipose whirlwind as their health care costs skyrocket and they feverishly brush up on their atrophied critical care skills. Either that or when we switch back we are going to be minus a lot of our citizens.
Next: The annual “Welcome to Intern Year” article. I promise.

Kabuki Medicine and other Wonderful Tales

Kabuki Medicine

In one month I have had Mary as a patient four times. I have also noticed her roaming restlessly through the department on days when some other resident had the bad luck to pick up her chart. I would not be exaggerating if I said that she has been a patient in our department thirty times this year and the Lord only knows how many times at other Emergency rooms in the area. She is a huge consumer of emergency services and no one dares tell her to pound sand when she presents with one bogus complaint or another because one day, after crying wolf for her whole life, she is really going to be sick and if she dies the usual compassion fascists will descend on us like self-righteous harpies.

Thus do we regularly ignore common sense and, putting on our best kabuki faces, take every episode of chest pain, abdominal pain, shortness of breath, and near-syncope completely seriously pretending that we have not spent hundreds of thousands of the taxpayer’s dollars ruling out everything except drug addiction. It would be more cost effective if we just gave her perscriptions for all the oxycontin she wanted provided she limited her visits to once a month. Instead we enact the the traditional Kabuki drama where she assumes the role of a patient and we pretend to be her doctors. We stamp and posture, reciting our ritualistic lines while she demurely assumes the character of someone we actually can treat. Five acts later we discharge her, plus or minus a six-pack of vicodin, depending on how badly we want to get her out of the department.
File this under getting what you pay for. Putting asided the usual policy wonkery, the real problem of American medical care is the complete absence of common sense. Mary is not unique. She is just a very visible symbol of a society that is ridiculously risk averse and consequently ridiculoulsy over-doctored. In a perfect world, someone would meet her at the door and say, “No. You are not getting drugs here.” If she departed chastened from our door and died…oh, let’s just say from a perforated bowel… a reasonable jury, assuming the case ever went to trial, would decide that it was a darn shame but understandable given her pattern of abusing emergency services.

Of course this would never happen. In the real world we are cautious to the point of foolishness, at least if we equate foolishness with a cavalier disregard for money.
Consider, as one example, the typical cardiac work-up and the vast sums of money wasted every year on diagnostic testing and empiric treatment of patients with ridiculously low pre-test probabilities of being sick. (In other words, they are not sick.) A young male with no risk factors for heart disease should not need a complete cardiac work-up when he presents with chest discomfort as it is almost certainly going to end up being musculoskeletal pain, reflux, or anxiety. And yet the patient inevitably gets the whole enchilada including an expensive stress test and occasionally an admission if he is deemed to be unrealiable for follow up (because if he is told to return in the morning for his stress test, forgets, and dies three years later it is our fault). Now, it may come to pass that one day, out of ten thousand thirty-year-old otherwise healthy men you will isolate the one who does, in fact, have early coronary artery disease…but then you probably would have picked him out just from the history and review of systems. I don’t deny that if I were that one guy I’d be pretty happy that our system is structured to spend billions protecting against lightning strikes but the fact remains that we are spending billions with a very little to show for it in actual treatment or prevention of morbidity.

My point? I am getting tired of saying it and I will soon stop. Because of the highly litigious nature of American society, there is no incentive to exercise common sense. In fact, there is a perverse incentive to spend money like drunken Marines in a brothel because there is no allowance in American medicine for mistakes. The standard of care has become absolute zero-defect which costs money…but the key is that our system is so adept at shifting costs that it always appears to be somebody else’s money.

Potemkin Medical Care
Cuban health care is so good that thousands of Americans risk their lives every year on flimsy boats and makeshift rafts in a desperate attempt to make it across the shark-infested waters of the Straits of Florida. Many perish in the endeavor and the 90-mile strait is littered with the floating corpses of uninsured Americans, many still attached to their now empty home oxygen cyliinders.

Ha ha. No, not really. Still, as the idee fixe of the pseudo-intelligentsia is the efficiency and general superiority of Cuban health care it is only a matter of time. We’ve all heard the mantra. The Cubans, it seems, spend a twentieth per capita of what we spend on health care but, mirabile dictu, have better outcomes and better access to medical care. Michael Moore, a man who knows as much about medicine as I know about making documentary films (i.e. nothing), has even made a movie based on this premise.
Leaving aside the fact that Cuba is a Soviet-style dictatorship where the official statistics are manipulated to show the Dear Leader in the best possible light, ignoring for the moment that Cuba has the usual three-tier medical system of every worker’s paradise (one for the apparatchicks, one for the proles, and a Potemkin hospital or two for the tourists), and even forgetting the inexplicable love of the American left for a dictator and a society from which people are willing to risk death fleeing…leaving aside all of this I just want to know why, in a society with a per capita income of just 300 dollars per year they manage to spend so much money with so little to show for it.

The per capita income in the United States is about $40,000 per year or about 130 times that of a typical Cuban. Cuban doctors make about three hundred dollars per year or about half of what the typical American family, even those in the dependocracy, spend for cable television. Cuban nurses probably make what my young children get as an allowance. Since labor costs are the biggest expense in health care both here and in Cuba, I just want to know why the Cubans are spending so much money on health care and still have a life expectancy less than the United States. Something doesn’t add up. Cuba is 130 times poorer than the United States and yet, in relative terms spends five times as much on health care.

Oh my long-suffering readers, do not yearn for Cuban-style medical care in the hopes that it will be cheap. It’s cheap for Cubans because Cuba is a third world country where everyone is poor. In Cuba a doctor might be willing to work for fifty bucks a month but in the United States, any enterprising teenager can make 20 times that amount working as a taco jockey. In other words, unless you plan on making everyone poor, good luck getting people to work at the hospital wiping yer’ grannies ass or coming at night to admit a patient for the kind of wages it would require to Cubanize American medicine.

Socialized Medicine: Survival of the Fittest (Addendum)

See, you folks don’t get it. If all you expect the government to provide is crappy and relatively inexpensive primary care and would be content to eschew the expensive, admittedly low-yield technological and labor intensive medical care that we currently waste on the elderly, the terminally ill, and those with extremely complicated health problems like they do in most of the Socialist Freeloader Kingdoms…if this is what you want then why do you need the government to provide medical care? After all, in the big scheme of things a visit to your family doctor two or three times a year is not going to bankrupt the large majority of Americans. Surely even most of my poor patients could but give up their cell phones and instantly have the wherewithal to afford to take their children to a pediatrician now and then.

It’s the ICU stays, the heart caths, the chemotherapy, and half a hundred other treatments and procedures not typically associated with primary care that suck up most of the money. If you eliminated most of these things, none of which are even remotely available to most of the people in an advanced but highly socialized country like Greece, we too might be able to brag about our low per capita spending on health care. As an additional benefit, after a brief period of turmoil in which the usual helpless and useless patients who consume the lion’s share of medical care dollars died out in a Darwinian mass extinction, we could at last get down to the serious business of making our statistics look good.
The point is that what you want and expect from the government, the thing that sends you into fits of rapture as you justify the more advanced priorities of the Nanny-States-Across-the-Water which stress primary care and prevention over our highly advanced reactive medical care, is so ridiculously easy to provide for yourself that it would be criminally stupid to structure society to provide it as an entitlement if for no other reason than it would involve shoveling even more of the personal wealth of the productive sector into the voracious maw of government. Your money, money that is not just paper or electrons but a voucher for your hard work, will be frittered away in the usual bureaucratic orgy of waste and inefficiency and contribute nothing to the prosperity of the nation.

All for the sake of avoiding having to pay for a couple of lousy doctor visits.

Kingdom Come

I could count the openings in the radiator grill of the truck that killed me and as I lost conciousness I noted with satisfaction that it was a good old-fashioned International Harvester of a kind that I had seen thousands of times but never from that close.

And then the cool darkness closed around me and I slept.

After what seemed like years I was awakened by a faint white light in the distance. I saw someone beckoning to me from the light which became brighter as it drew closer and I was afraid. Afraid to leave the comfortable darkness. Afraid of the long swim to the light which now burned with a cold incandescent fire.

“Come into the light,” said the voice and as I rose towards it I recognized the speaker.

“Uncle Jedidiah?” I said, “Is that you?”

“None other,” said the voice as he extended his hand to pull me firmly out of the darkness.

“I haven’t seen you in forty years,” I said in wonder, “Since you died, I mean. Aren’t you dead?.”

“Oh, I’m dead, as dead as a doornail. I’m sorry to be the one to break it to you but so are you.”

“I figured as much,” I said, “Where am I? Is this heaven?”

“Not quite,” Replied Uncle Jedidiah, “You’re in the Purgatory Room.”

“Purgatory Department!” corrected a winged creature carrying a flaming sword, “It’s a department, not a room.”

“Uh, right…anyway, you’re in the Purgatory Department waiting to be admitted to Heaven,” said Uncle jedidiah, “And I’m afraid it’s going to be a while.”

“You mean you’ve been waiting for forty years? What gives, Uncle? I remember you were a pretty good Catholic, went to mass every week, said your prayers. Even the priest thought you were a pretty righteous guy. If anybody could get to heaven quickly surely it would be you.”

“Oh, I did all right when I was alive,” said Uncle Jedidiah looking down modestly and pretending to examine his fingernails, “I ate a little meat on Friday and cursed a little. I wasn’t perfect you know.”

“Yeah, but surely a couple of Hail Marys and a few Our Fathers could have covered it,” I was incredulous, “Fifty years? Come on now. What chance do I have?”

“Well, it’s not exactly merit-based anymore now that they’ve gone to a Single Penance system so your chances are as good as anybody else’s.”

“Single Penance? What’s that?” I asked.

“It’s new. Instead of being responsible for your own sins, somebody repents for you so you don’t have to do it yourself. It’s supposed to ensure equal access to Heaven for the under-repentant,” Said Uncle Jedidiah.

“So that explains the wait.”

“At first it wasn’t too bad,” said Uncle Jedidiah leading me around a group of bikers eating vending machine locusts and honey, “They started with the Protestants which was all right, I guess. I mean I could see the rationale for that. But then they decided to start letting in the Hindus and the Moslems. I don’t have to tell you the penance problems that posed.”

Uncle Jedidiah motioned me to a place at the end of a line which stretched for miles.

“Pretty much anybody can get in now,” He continued,”You really have to have committed some kind of major crime against humanity not to…which explains why the Back Street Boys might not make it. But pretty much no matter what you do somebody else will do your penance. About the only people they don’t let in are the Methodists, for obvious reasons, but other than that it really makes no difference what you have done.”

“Can’t we just repent ourselves and eliminate the wait?” I asked taking a number from a brazen tripod which gleamed with a holy luster.

“Well, of course not,” said Uncle Jedidiah looking puzzled, “That wouldn’t be fair, now would it? That would give people who were responsible and self-disciplined an unfair advantage compared to, oh, let’s say pedophiles. Surely we can’t have that.”

“I don’t know Uncle, it sounds good but who’s doing all of the repenting if nobody is expected to do it for themselves?”

“Well, there’s the rub,” said Uncle Jedidiah ruefully,”There is apparently a distinct shortage of pentinents. At first they had the Archangels do it but there are only so many to go around. Then they started using Saints but even they have their limits and I know I don’t have to tell you how long it takes to make one. Eventually they started using mid-levels like Saint Assistants and Saint Practioners.”

“How’s that working?” I asked looking far into the distance at the line ahead of me which wound around pillars of clouds upon which, written in blazing letters of English and Spanish, were admonishments keep all manna in closed containers and to rate your sin on a ten-point scale.

“Here comes one now,” said Uncle Jedidiah, motioning to an officious looking fellow making his way towards us, “Ask him yourself.”

“Hi, I’m your pentinent-providor,” said the fellow, “I’m not actually a saint but I am just as well trained despite the fact that unlike saints who toil and suffer on earth for many years, often enduring martyrdom for their faith, I went to a rigourous two year program which cut out all of the useless stuff.”

A Seraphim, six-winged, rolled his many eyes and shook his head sadly as he flapped by.

My providor shot him a dirty look and just as he opened a book which looked suspiciously like a gold-plated DSM-IV, I felt a slight tingling in my chest like a distant electric shock. Then another which felt stronger. The Purgatory Department started to fade.

“Oh well,” said Uncle Jedidiah, “I guess i’ll be seeing you later. Just some advice. twenty years from now don’t ignore that rectal bleeding. I’m just saying…”

And then I gasped. The pain flooded over me and I was back.

Socialized Medicine: Survival of the Fittest

(My mother, who is an avid reader of my blog, is a native of Greece and while a fierce partisan of that country is never-the-less perplexed at the love so many of my readers have for socialized medicine of the kind which is the rule of life over there. I offer this brief description of a typical socialized system in a modern European country.-PB)
“Apoklistiki Nosocoma”

The hottest new career in Greece, a country with socialized health care and my family’s ancestral homeland, is the Apoklistiki Nosocoma, or “Private Nurse.” Because the public hospitals are so understaffed families routinely hire one of these trained nurse to watch over their relative while the low-paid government nurses do whatever it is they do for their small salary, a salary which is just enough to convince them to come to work but not enough to actually get them to do anything.

These private (or “elite” nurses) are brokered through the public hospitals in a tacit admission that the socialized system cannot provide decent medical care to the people.

But that’s how it is when nurses (or anybody else for that matter) are employees of the state and have jobs from which they can be dislodged only by the apocalypse or another Persian invasion. They will certainly not be fired for ignoring the patients. Not only is the pay low but, with the exception of a few zealots, there isn’t exactly a long line of Greeks waiting to work for those wages doing the kind of work that our well-compensated nurses do automatically. There are no incentives to work and no penalties for not working. The results are predictable. Not only are Greek public hospitals understaffed but the staff in ’em are not exactly chugging away efficiently.


Of course, if you want anything done in the Greek public medical system you can always pay extra for it with a well-placed bribe. Maybe a couple of hundred Euros in a fakelaki (envelope) to the general surgeon to put your father at the head of the line for a colectomy. Perhaps some well-placed Euros to the charge nurse to make sure she watches your sister. My mother, who lives in Greece, relates to me that this system of bribery is endemic and almost institutionalized. In a country where doctors who elect to work for the state barely make what a garbageman makes over here, not only are there shortages of trained doctors in the public system but they have very little incentive to make the system work and the fakelaki is necessary and expected.

In our country a homeless wino can be brought in for gastrointestinal bleeding and within 24 hours have everything including a sigmoid colectomy and a kitchen sink thrown at him while he is cared for no differently than the paying customers. No bribe is required and the concept of expecting one is unthinkable. In fact, our system, although expensive, provides such good care to everyone that the VIP and the wino are indistinguishable as patients.

In Greece on the other hand, enjoying as it does the bounty of socialized medicine, there is a three tiered system. In the first tier are the private hospitals which are the equal of anything we have in the United States. Unlike our hospitals however, they are in no way charity institutions and only cater to the wealthy. In the second tier is the public hospital system where those who can afford it bribe doctors and nurses and even hire maids to clean their relative’s otherwise filthy rooms. In the third and bottom tier are the poor who lay in cots in the hallways of the crowded public hospitals relying on their relatives for the basics of life and nursing care.
No relatives, no care. Greek public hospitals provide only the rudiments of services to their patients. The condition of the food service in most of them, for example, would be a scandal in the United States. Patient are fed indifferently from rat and roach-infested kitchens and the concept of nutrition seems to be unknown. It would be a national embarrasment except, in typical European fashion, the Greeks take great pains to criticise the United States while their own post-operative patients slowly starve to death. An ironic state of affairs in an otherwise modern European country.
Even getting admitted to the hospital is a difficult process requiring the ubiquitous fakelaki. We would find it hard to believe accustomed as we are to almost instantaneous access to the full panoply of medical resources but in Greece if you have a life-threatening condition, say colon cancer or PORT-score maximizing pneumonia, and you rely on the socialized system you are probably out of luck and could die before you are admitted. The waiting list for what we consider to be routine medical care is hopelessly long.

And things like hemodialysis or Critical Care? Not if you are elderly or poor. You are going to die, just like Darwin intended, because in Greece as in most socialized countries they do not keep the weak and the helpless alive when they become a burden to the state. That’s the secret of socialized medicine. It’s like Logan’s Run. When your life-clock runs out you are done. Finito. Buh-bye. So sorry. Appreciate the taxes and everything but now it’s time to pay the bazouki player.

What’s my point? Nothing really, except you get what you pay for. Providing the high level of medical care that is expected by the American public is not cheap. Attempts to nationalize, socialize, quasi-socialize, or we-swear-we’re-not-going-to-socialize will do nothing to lower costs unless medical care is strictly and severely rationed. Oh sure, you can get yer’ stinking ineffectual primary care provided by a poorly-trained Nurse Practitioner but when your heart starts to give out or you need a new knee, well, you will see the truth to the adage that free health care is great as long as you don’t need it.

Curbing Health Care Spending, Belling the Cat, and Other Dangerous Activities

Where the Money Goes

American medical care is expensive and only getting more expensive. I blame the nurses. Think about it. Who is always at the hospital drawing their princely 25-to-40-dollar-an-hour salary? Who must provide continous coverage for the patients? Who are the most numerous employees of the hospital?

Nurses, that’s who.

Think about it. Doctors may make a lot of money but in most hospitals they are pretty thin on the ground. On the other hand you can’t swing a JCAHO-compliant dead cat without hitting four or five nurses. They’re everywhere. Thick as thieves, robbing the public blind with their salary demands. What gives them the right to make their ill-gotten five-figure salaries when the typical American struggles, yes struggles, to pay for all of those cool features on their cell phones?

It’s a scandal. Until we address nurse’s pay health care will continue to get more and more expensive.

And don’t even get me started on the respiratory therapists, pharmacists, and others who unfairly try to parlay their many years of education into the high wages thus forcing the sturdy peasantry to choose between their blood pressure medications and their personal watercraft.

Made of Money

On the subject of health care spending, it is fairly obvious to anybody who has spent any time in a hospital why our nation spends so much on health care. Just pick up a random chart from any nurse’s station and the chances are you could elucidate a medical history that reads like a pathology textbook. I used to be amazed that one person could have so many diseases and so many procedures. Now that I have grown used to Homo Polymorbidus I am more amazed at the rare patient who has no past medical history and takes no medications. Hell, even most kids are on something.

So it’s true that we spend a lot of money but keeping the typical ninety-year-old alive isn’t cheap and is only made possible by a stunning amount of medical care, the cumulative amount of which is probably in the millions of dollars. In one two-month stretch in the Emergency Department I saw the same nonagenarian three times for essentially the same complaint. The triage note said “Altered Mental Status” but it might just as well have said “The Nursing Home Panicked When the Patient Seemed a Little More Sluggish Than Usual.”

Folks, when you’re ninety you just start slowing down a tad, especially if you have been in a nursing home since the Reagan adminstration and sit at the pinnacle of the medical food chain as a top predator of medical services. That much medical care would wear anybody out. I am not advocating discarding the elderly. It’s just that somewhere in the feeding frenzy a point is passed where we need to step back and say, “What in the hell are we thinking?” We admitted the above-mentioned patient twice and as far as I know she has returned to her nursing home in the same mostly demented state that is her baseline and where she will lie, collecting bed sores, until the next time we save her life.

Now, one patient is not going to bankrupt the system. The infrastructure is in place after all, so what’s it going to hurt sending one frail little old lady up to the ICU? But that’s kind of the point. It’s the infrastructure that costs money, not the individual patient. Collectively, the ethos that requires us to keep everyone alive at all costs all the time requires that hospitals have a commensurate level of facilities and staff. It also requires an army of highly paid specialists to coax the last dregs of life out of the actively dying.

Is this a bad thing? I can’t say. When I was twenty I thought life was over at forty. Now that I have passed forty I can see that life is still worth living even if I can no longer run six-minute miles. Maybe despite being a doddering wreck at eighty I won’t be ready to shuffle unselfishly off of my mortal coil so as not inconvenience my children. But keeping me going will cost money. Everything that requires time and resources that belong to somebody else does. The expectation that it can be otherwise is ridiculous, as is the religious faith of the Single Payer zealots who believe that by adding an expensive layer of ineffectual free primary care somehow everything is going to be all right.

In no way is any socialized, quasi-socialized, or we-swear-it-aint-socialized scheme going to do a thing to lower the cost of medical care unless fundamental changes are made in the way we conduct health care business. As these fundamental changes mostly involve the rationing of care for people who expect limitless access, the voting public is never going to buy it unless they are tricked into it with promises of a shining all-you-can-eat medical buffet on a hill. This is a promise that cannot possibly be kept except by continuing to increase health care spending. After all, what politician has the guts to tell the people that they can’t have it all? To do so is counterproductive anyways, even for an honest politician of which there are many, because it is political suicide. No one is going to bell this cat.

What Are We Really Getting for Our Money, Anyways?

I’m not entirely convinced that a lot of what we do on a routine basis is really worth the money. Take a simple thing like Coumadin. Coumadin inhibits several of the factors in blood that makes it form clots. The lay people call it a blood thinner (although it doesn’t really make blood any thinner) and some even know that it was first used a rat poison.

Coumadin is widely prescribed for all manners of conditions, particularly for atrial fibrillation to prevent clots from forming in the dead spaces of the quivering left atria. Pieces can break off of these clots and travel to practically any organ in the body where they can abruptly shut off blood flow. In the brain this is called a stroke and is a particularly deadly complication of chronic atrial fibrillation.

And yet coumadin is not a benign drug and can cause complications every bit as bad a stroke. The interesting thing is that without coumadin, the risk of forming an atrial clot a stroke is about six percent per year. Just taking aspirin, a relatively safe drug that “thins” the blood by preventing platelets from clumping together, lowers your risk to three percent per year. Using coumadin lowers the risk to one percent per year. So you see that not only is the risk of clot formation stroke in atrial fibrillation fairly low to begin with but to achieve an almost insignificant reduction in risk we habitually pick a dangerous drug that is likely responsible for billions of dollars worth of side effects over a the safer drug.

That’s kind of the gestalt of American medicine. The drive to spend whatever it takes to extract the last bit of life out of everybody even though we are already well into the realm of diminshing marginal returns for a large portion of what we spend.

Don’t Just Do Something, Stand There: Part Three

(In which we mostly belabor the obvious.-PB)

Mostly Over-doctored

How much health insurance do most people need for most of their lives? The answer is none. Most people are fairly healthy and have mostly healthy children who could probably manage to go years between visits to the doctor. When they do go, it is mostly for a minor self-limiting complaint or a long-term health problem that is under good control. Insurance, and forgive me for belaboring the obvious, is supposed to ameliorate the effects of unforseen and and rare events which a visit to the doctor for a cough or an ear infection is most certainly not. We insure our houses against fire, for example, not because fires are common but because the cost of rebuilding a house, the repository of most people’s wealth, is more than most of us can afford to pay. There is no such thing as “lawn mowing insurance” or “garage floor painting” insurance because these tasks are routine and an expected part of home ownership. Putting on a new roof stings a little, I admit, but most normal maintenance of a home won’t bankrupt anybody.

The trouble with health insurance is that it’s not really insurance at all, at least not how most people view their other kinds of insurance. Rather than serving to protect us from the catastrophic financial effects of a major illness, health insurance has become an expensive middleman between the consumers and producers of medical services. If your car needs an oil change, you change it. If you need new tires you buy them. If you need to go to the doctor for your annual physical however, you engage a complicated bureacracy which exists to shift costs from one set of consumers to another. This is why the health insurance for a typical family may cost them or their employer in the neighborhood of twelve to fifteen thousand dollars per year even though their actual expenditures for medical care in any given year are not even close to that amount.

Routine health care is not even completely covered under even the most expensive health plans. There is always a copay and a lot of essential services that the typical family really needs, such as dental and vision, are either not covered or involve an even bigger copay. It has to be this way because health insurance is a ponzi scheme with hordes of investors at the bottom of the pyramid paying the dividends of those at the top who are, in this case, the extremely sick and the uninsured.

It wasn’t always like this. Our current model of health insurance is the result of two historical trends, the first of which was the explosion of medical knowledge and technology in the 1960s. Before this time medical care was relatively cheap because there wasn’t really that much that could be done. Hospitals were more like hotels than the patient processing plants they are today and the amount of doctoring received by a patient was limited by the amount of doctoring that could actually be done. This also limited the number and sophistication of the support staff and equipment required for a typical hospital or clinic. Health insurance before that time was rare and most people payed out of pocket for their doctor visits. It was just expected. Society had not been medicalized and people grew old and died without fanfare because there was nothing else to do.

This is not the case today where our ICUs and nursing homes are filled with the warm dead, people who in many cases are only kept alive at the end of a long and expensive journey through the medical system by increasingly expensive and futile medical heroism.

So there is no question that the real cost of medical care has increased, on the high end anyways.

The other trend was the incredibly high top marginal income tax rates which began to rise in the 1920s, peaked at 94 percent in the forties and, before President Reagan (PBUHN) took an axe to them in the mid-eighties, had stabilized in the high seventy percent range. The result was that increasing the pay of white collar and skilled labor in the post-war boom wasn’t much of an incentive as a raise was often eaten up by increased taxes in the higher income brackets. This was the age when companies started offering fringe benefits to their employees in lieu of increased salaries. One of these was comprehensive health insurance which has now become an expected part of the compensation package for any good job even though the original rationale for offering it has disappeared. Most people would probably be better served if they got the raise and payed for their own medical care as the marginal rates are not nearly as high as they were forty years ago.

The income tax is progressive of course, and the middle-class hardly pay any compared to the upper middle-class and the wealthy. In this case, there would seem to be even more of an incentive for middle-class employees to prefer the money over the insurance. Money is money. Insurance is wasted money unless you need it.

The unfortunate consequence of almost universal health insurance (because 85 percent of Americans are covered under some insurance plan or another) is that the true cost of health care is masked from the consumer. Everybody complains about the cost of medical care but it is a generalized, non-specific complaint. The high cost of medical care is an abstraction to most people most of the time. They have the occasional hospital stay, pay a small fraction of the total bill, let insurance handle the rest, shrug their shoulders and move on. The poor and the government-insured care even less because they are never expected to pay much, if anything, for most of their medical care. If the insured had to pay the complete bill the cries of outrage would send fear and panic through the entire health care industry.

The Big Lie, the scare tactic used by the usual suspects in their craven lust for political power is that people need comprehensive health insurance. They most certainly do not. Most people most of the time need so little medical care that most of the money spent either by them, their employer, or the government is wasted as far as it benefits them. Consequently, In a country where almost everyone can borrow money for automobiles, personal watercraft, and all manners of luxury items, there is no reason why most of us should not be expected to pay for most of our medical care most of the time (even if we have to borrow a little). No reason, that is, except that we have been conditioned to expect it for free. Not to mention that to merely suggest that maybe, perhaps, just possibly, a visit to the doctor is no different from a financial point of view than a visit to the hair salon would be political suicide for anyone with the guts to say it.

It’s easier to give other people’s money away, and more gratifying too because it earns one the reputation for being compassionate even if the long term consequences are harmful to the public.

There is the difference between what people want and what they need. While everybody wants somebody else to pick up the tab, the tab is going to bankrupt the nation. What most people need is an inexpensive high-deductible insurance policy to protect themselves against financial disaster if they should require some big-ticket medical care. Almost nobody, for example, can afford a kidney transplant or even the medical consequences of a serious car accident. Not to mention that people do grow old and eventually, many but not most, will require the expenditure of fairly large sums of money to preserve their quality of life.

The key thing to keep in mind is that the various plans proposed to insure the entire nation will do nothing to lower the cost of medical care because they are just another scheme to shift the costs from one set of consumers to the other. The only difference will be that instead of half, every single health care dollar will take a trip through the federal sausage mill. The money is going to come out of somebody’s pocket and it’s not going to be the government which has no pockets, just hands to grab from one to give to another

It’s just rearranging deck chairs on the Titanic. Twenty years from now when medical spending has doubled as a percentage of GDP the same people will be crying the same tears over the same problem because the entropy of government winds down to expecting less and less of the people while trying to give them more and more. This is why the concept of Health Savings Accounts (not to mention privatizing Social Security) invokes such howls of rage from our ruling elites. Not only do they hold the people in contempt thinking them incapable of planning for their own future but the money tied up in these accounts and owned by citizens is just another chunk of money that cannot be stuffed into the voracious maw of the political influence machine.

As for the poor, well, we live in a society that is both opportunistic and compassionate. It would be demoralizing to our nation to have the disparities of medical access so wide that the poor and ignorant suffer or die from conditions that those who can think and plan ahead easily eacape. We will, unfortunately, always need to give medical care as charity. But the key here is that primary care is no bargain. The connection between good health and acccess to primary care is tenuous. The factors which contribute to poverty and ignorance also contribute to poor health and we have been fighting those since the Johnson Administration with little or no success. Bad health in the poor is mostly a the result of social problems which have shown a surprising resistance to huge doses of federal dollars. Dumping even more money onto the poor is mostly the same as trying to treat a disease with an antibiotic to which it is resistant. Staph Aureus laughs at your ineffectual pennicilin. The poor will laugh and ignore your ineffectual primary care.

What the poor need is the same as everybody else. Major medical insurance for which, if it absolutley must, the goverenment can pay. We certainly pay enough to support the poor now. May as well spend it where it will be effective, that is, on management of the acute health problems that people who don’t think and plan ahead are going to get no matter what we do. To hell with it.

There are many conflicting forces in medical care, each one trying to stiff the other with the bill. The insurance companies want to pay as little in claims as possible which is understandable given the nature of their business. The medical industry, from physicians to the lady mopping the hospital floors, would like to get paid fairly for their services. The government wrings its hands at the cost but at the same time would like as many people dependent on government as possible. The people want all the medical care they can eat but they want somebody else to pay for it.

Nobody else can pay for it unless we become a nation with a government whose sole function is to provide health and other benefits to a universal dependency class in some decaying freeloader heaven.

Don’t Just Do Something, Stand There: Part Two

(Medical care is expensive, no doubt about it, but the remedies proposed by the usual suspects who hope to leverage the problem into political power don’t address the real factors driving up the cost. Maybe I’m just not an excitable fellow but I like to keep a cool head and not get swept up in the hysteria, especially as it is being lead by people who are themselves part of the problem-PB)

Zero Defect

You get what you pay for.

Consider the space shuttle, a technological marvel conceived in the 1970s to revolutionize space transportation by using a reusable space vehicle to drastically decrease the cost-per-pound of lifting payloads into orbit. First flown in 1981, the fleet of incredibly complex and expensive orbiters have yet to achieve their stated purpose of making launches economical and have instead become something of a boondoggle to NASA, sucking vast amounts of money out of less glamorous but probably more important space endeavors. It turns out that disposable rockets are significantly cheaper on a cost-per-pound-to-orbit basis because they are less complex, unmanned, and do not have to be refurbished between flights. The cost of the shuttle program has been almost $150 billion dollars or a little more than one billion dollars per flight for each of the 117 missions. Unmanned rockets, even big ones, aren’t nearly that expensive.

The shuttle is more expensive than was hoped largely due to a rigid zero-defect mentality on the part of NASA. Even a minor malfunction can result in the complete loss of the crew and a two billion dollar vehicle. Consequently, NASA takes an already legendary obsession with perfection to a new level to ensure the absolute reliability of the orbiter before each launch. This obsession is built into the vehicle through redundant systems and meticulous quality control, carries on to the launch where the smallest anamoly can scrub the mission (leading to costly defueling and reinspection), and finishes with an exhaustive post-flight check where the engines and most major sub-systems are disassembled and inspected.

At every stage of the process a small army of engineers and technicians orchestrate a clumsy bureaucratic exercise to document contractually stipulated compliance with procedures and specification. And yet, despite their best efforts, to date there have been two catastrophic losses of crews and vehicles for a failure rate of about two percent.

It wasn’t supposed to be this way but perfection isn’t cheap. If you adopt a zero-defect mentality, you are going to have to pay for it and you will rapidly reach a point where large amounts of money need to be spent for infinitessimal increments of improvement.

Consider modern American medicine which, because it operates in a predatory legal environment, is also expected to be zero defect. It is hard for some people to believe but a physician can be sued by a patient who he treated many years before for a condition that may of may not have been the presenting complaint but which was not discovered at the time even though a reasonable standard of care was used. The patient may even have been told to return if the symptoms did not resolve but for whatever reason was “lost to follow-up” or whichever creepy, politically correct phrase is selected to divorce the patient from his responsibilities, in this case the responsibility to be concerned enough about his health to be more than a passive observer or some kind of oblivious passenger.

The physican’s records will be scrutinized by a rapacious attorney and any mistake or ommission, no matter how slight, will be used to construct a case which, while perhaps not the multi-million dollar jackpot of which all indigent patients dream, may likely be settled out of court to avoid the expense of a trial. It’s a living for many attorneys.

This zero defect mentality costs money and very little of it improves patient care. Mostly it goes to cover the massive cost of defensive medicine which is what, I would dare say from personal experience, most of American medicine comes down to. We know better of course, but it is a lot easier to obtain the CT or order the test than to defend your perfectly reasonable, evidence-based rationale for not obtaining it. We also probably admit many more people than need to be admitted out of the fear of allowing patients to be responsible for their own outpatient follow-up.

A healthy respect for the possibility of error is part of medicine and cannot be discounted. On the other hand, what we have today is an abject terror of making a mistake. Unfortunately, unlike NASA, we are not working with professionals who have contractual obligations that they must honor, at least none that are enforceable. The trendier hospitals make a big deal about their carefully crafted Statements of Patient Rights and Responsibilities but it’s all just fluff to keep Press Ganey, the insatiable God of the Bureaucracy, happy. In our medical system, patients have no responsibilites and therefore the physicians must play a constant game of chess with opponents who moves their pieces at random and out of turn.

The public has to decided what it wants. They can have a reasonable level of relatively inexpensive medical care that relies as much as possible on the clinical judgement of physicians and their own high level of personal accountability with the understanding that occasionally something is going to be missed or they can have a hugely expensive system of medical care where everybody gets the million-dollar workup on the rare chance that something is caught that would otherwise not have been.

But being zero defect costs money and you pay for what you get.