Progressive Americans have this much going for them: they can, without any reservations, second thoughts (or perhaps even first thoughts), enthusiastically and wholeheartedly support Obamacare’s individual mandate. For them, the individual mandate is an unalloyed good. Not only does it enable Obamacare to proceed, thus giving the government unprecedented control over every aspect of American healthcare, but it also establishes the authority of the government to control the economic activity of individuals. This new authority will come in very handy as our leaders continue working toward redistributive justice. So if you’re a Progressive, what’s not to like about the individual mandate?

Conservative Americans do not have it so easy. In principle, of course, the very idea of an individual mandate is constitutional heresy to a conservative, since it violates not only the letter but the very spirit of the Constitution. This is why, over the past three years, opposing the individual mandate has become for conservatives a more fundamental litmus test than opposing abortion. Accordingly, it is conservatives who have launched the constitutional challenge to the individual mandate, and who have now succeeded in bringing it before the Supreme Court, and who have based their chief strategy for bringing down Obamacare on the idea that the Supremes will agree with them about it.

DrRich, like most conservatives, is aghast at the idea that the Court might actually find the individual mandate to be compatible with the Constitution. Such an expansion of the power of the Central Authority over the lives of individuals will essentially gut the main idea behind our founding, and send us even more rapidly down the path toward tyranny.

But as he contemplates how he might feel on the day the Supreme Court finally strikes down the individual mandate, DrRich can’t help conjuring up the last scene from The Graduate. In that scene, Dustin Hoffman, who has just burst into the church and fought through a horde of wedding guests to grab his girl from the altar, and, with her in tow, has fought his way past the stunned groom and back through the angry crowd, and having at last jumped with her onto a city bus, is now sitting breathlessly, his hard-won love at his side, as the bus pulls away leaving their pursuers behind. And as that last scene fades, his look of elation at finally winning his heart’s desire gradually slackens, and transforms into a look of utter panic, a look that silently beseeches, “Now what?” Or, perhaps, “What have I done?”

DrRich thinks that’s what will happen to Republicans on the day the individual mandate is declared unconstitutional.

There is a reason, dear reader, that Mitt Romney, Newt Gingrich, and the Heritage Foundation, all of whom claim to be conservatives, at one time or another supported something very much like Obama’s individual mandate. That reason is: it is very difficult to conceive of a workable, market-based solution to our healthcare mess without one.

Any scheme for reforming healthcare that is based on private health insurance will fail if a substantial proportion of the population declines to purchase health insurance. Whether people have chosen to acquire health insurance or not, they will still get sick. And when the uninsured get sick there are only two choices.

The first choice is to refuse them care. Libertarians have no problem with this. They believe that if you want some healthcare, you should pay for it yourself. If you choose not to buy health insurance, or otherwise fail to make arrangements to pay for healthcare should it turn out that you need some (as well you might, if you engage in all the activities and abuse all the substances that libertarians say is your right), well, that’s too bad for you. Let your painful and untimely demise serve as an object lesson to everyone else, so that perhaps they will make better personal choices. Most non-libertarians, however, find this option abhorrent.

The second choice is to take care of the uninsured anyway. If you do that, not only do you drive up the cost of health insurance for people who have chosen to buy it, but you also create a huge incentive for people to not buy it in the first place.

This is why Republicans or conservatives who have thought deeply about healthcare reform (Gingrich, the Heritage Foundation), or who have actually instituted healthcare reform (Romney), will often settle upon a solution that incorporates something very much like President Obama’s individual mandate. Unless everyone is strongly “incented” to buy health insurance, a market-based healthcare system will collapse.

More to the point, Republicans ought to recognize that, while it seems to have wound up that way, the individual mandate in Obamacare did not start out as a sneaky way to undermine the Constitution. It was, in fact, a necessary concession to the more conservative of the Democratic members of Congress. President Obama and his minions (or handlers, depending on which talk show hosts you listen to) are on record as saying that their real goal is a single-payer, government-controlled healthcare system. And there is no reason in a single-payer, government-controlled healthcare system to invoke anything like an individual mandate to purchase insurance. The President would have been quite happy without any individual mandate, if he could have gotten his way in the first place.

The individual mandate was inserted into Obamacare purely as a necessary component of healthcare reforms that are ostensibly based on private health insurance, which is the only kind of reform the President could possibly get through even a Democratic Congress in 2010.

If the Supreme Court declares the individual mandate to be constitutional (which will violate everything DrRich holds dear about America), then it’s a huge win for Obamacare.

But if they declare it unconstitutional, that will trigger the Republican’s real problems.

Republicans, Democrats and federal judges all seem to agree that without the individual mandate, Obamacare is infeasible. The moment the mandate is declared unconstitutional, Obamacare disappears.

And this will create a “Graduate” moment. There the Republicans will be, sitting on the bus with the healthcare system they have just saved from the handsome-but-arrogant groom who had Big Plans for it, and heading to – where?  They can’t just go back to the old healthcare system; we’re past that. The health insurance industry has made it plain that their business model is broken, which is why they acceded to and even campaigned for Obamacare (a system under which they are to become federally-regulated public utilities) in the first place. Should Republicans institute their own market-based healthcare reforms? Good idea! But what do they do about the people who choose not to buy private insurance, now that they have had mandates to purchase declared unconstitutional? And even if they have an answer to that question (which they do not), do they have a plan ready to go, one that can be implemented quickly, before the healthcare system implodes? (Remember, Republicans, you will be dealing with a health insurance industry that has run out its string, and that will be at least angry if not panicked at the demise of its public-utility end-game.)

As it happens, DrRich himself has proposed a fix for the healthcare system that addresses all these problems – a system that is based on individual choice and incorporates private insurance, and at the same time covers everyone without any individual mandate, and controls healthcare costs to boot. The details are entirely irrelevant at the moment, and DrRich will not bore his readers with them now. (If you’re interested you can buy a copy of his book in Kindle format for five bucks, or if that’s too steep you can read an outline of his plan here for free.) The point is that workable solutions to our healthcare problems are indeed imaginable. The likes of DrRich has imagined such a thing, and so have others. But Republican candidates for President, and Republican congressional leaders, are not creating these solutions. Instead, they are steering us into a blind alley.

Here is what DrRich fears. When the individual mandate is declared unconstitutional next June, the Republican celebration will last all of 7.5 minutes. The insurance industry will make it very clear very quickly that they simply will no longer be able to function, and to have any hope of survival they will have to resume cherrypicking healthy patients, massively increasing premiums, denying recommended care, and dropping subscribers when they get sick. Even with these drastic steps, they will say, there’s no guarantee that health insurance will still be available for most Americans in a year or two. And at the time these astounding revelations are made, the Republicans won’t even be finished choosing a nominee, let alone be able to articulate a coherent plan for replacing Obamacare. By Independence Day panic will reign across the land.

The President will then make a speech. He will say, “We tried, America. In the spirit of bipartisanship we tried to give Republicans a system of market-based healthcare reforms, just like they say they wanted. But that kind of system requires an individual mandate, and our misguided friends on the right have now shot the individual mandate through the head. And when the American people ask those same Republicans who brought this disaster upon us, “Now what?” the American people get no answer. The Republicans are quite good at destroying healthcare solutions, but are hopeless when it comes to creating them. And you can hear for yourselves what the health insurers are now threatening to do to all of us when we get sick. It will be just like it was before, but much, much worse.

“We tried, America. We tried to create a market-based healthcare system that would be fair to all. But the Republicans, caring for nothing but their own selfish political fortunes, have blocked our efforts, and have left us all for dead.

“Fortunately, in a few short months you will be able to exercise your God-given right as Americans to choose. If you want to, you can vote into office the Republicans, the people who have traded your healthcare security and that of your family in favor of the chaos we are all witnessing today. Or you can re-elect me, and you can give me a Congress I can work with, and let us try to salvage something good from the ruins of the glorious reforms we fought so hard for the last time. Let us try to give you the best healthcare system that is still possible, given the new constraints the Republicans have now made for us. While you and I might not have started out wanting a healthcare system run entirely by the government, today our choice is either that, or the chaos, pain, suffering, disability and death that, thanks to the good offices of the Republicans and their friends in the health insurance industry, are now staring us in the face. But this is not the first time Americans have stared evil in the face. We have done it before, and we have always prevailed.

“We tried, America. We tried – but the Republicans denied, and babies died.

“My fellow Americans, in November you will have the opportunity to say no to the forces of evil, and to set this travesty right. I know the heart of Americans, and I know that you will do the right thing, not only for your own sake, but for the sake of your children, and your grandchildren, and generations of Americans yet unborn.*”

And when President Obama is finished laying out his argument, the Republican nominee, whoever he or she turns out to be, won’t know whether to cry, “Oops!” or “Nein, nein, nein!”

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*DrRich is a conservative but also a capitalist, and so his speechwriting services are available to the highest bidder. Mr. Obama, mutual “friends” in the DOJ have proven adept at tracking DrRich down when necessary, and will know how to contact him.

While Grand Rounds is normally the highlight of everybody’s week here in the medical blogosphere, this time it’s different. This week, we are all – each and every one of us  – completely distracted by the most wonderful sense of expectation and joy, to the exclusion of virtually every other human emotion. For DrRich, at least, the feeling puts him in mind of the giddy anticipation he experienced on, say, his 5th Christmas eve, when he was still young enough to consider Santa Claus a magical-but-real agent of earthly delights. (This was before DrRich realized that Santa, being obese, is actually a great menace to society.)

For this, dear reader, is the week when President Obama will turn his considerable powers of intellect, at long last, to the issue of jobs. The President indicated to us more than a month ago that he would, in his own good time, present to us his program for fixing the horrific and prolonged unemployment problem which now affects most American families in some way. And thus realizing that a solution is finally at hand, we in the great unwashed masses have waited, as patiently as we could, through earthquakes, hurricanes, Martha’s Vinyard vacations, and numerous pre-season football games, for the President to tell us the Answer. And, summoning together a Joint Session of Congress – a venue most often reserved for declarations of war and similar life-altering policy initiatives, thus confirming the momentous nature of his coming words – he will finally proclaim to us the Good News, a mere two days from now. One can cut the anticipation with a knife.

So, while it is indeed an honor to be hosting Grand Rounds during this historic week. DrRich must admit to finding it a little difficult to concentrate his efforts. No doubt readers will likewise find it a challenge to turn their attention away from the Big Event long enough to peruse the following posts – the best of the medical blogosphere this week.

But be assured that there is good stuff to follow. So, if you find yourself incapable of focusing your attention on Grand Rounds at the moment, simply bookmark this page, and return to it once your sense of soaring happiness returns (as it inevitably must) to a more normal state. Be assured that this week’s entries are timeless enough to outlive your ecstasy (an emotion which – alas! – to be effective, must always be transient).

So let us begin.

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DrRich – having been informed not long ago, by an actual U.S. Attorney who at that moment had him under a form of official duress, that the DOJ is well aware of this blog and the general tenor of its content – always likes to mention early in any long post (so that his minders do not have to read the whole thing) any items that might be helpful to the Administration. Accordingly, we open Grand Rounds this week with the announcement, posted in The Examining Room of Dr. Charles, of the 2011 Charles Prize for Poetry. Dr. Charles has been hosting this prestigious contest – which seeks and awards excellence in poetry touching on health, science or medicine – for some time now, and it has proven to be an exceedingly popular annual event.

In addition to the significant intrinsic merits that accompany the Charles Prize for Poetry, DrRich must note that Dr. Charles is also awarding a not-inconsiderable cash prize to the winners. That is, he is creating what, in our present economic environment, must be considered damned-near jobs. Encouraging employment in the career of poetry is something, DrRich thinks, the President should seriously consider before Thursday night, lest he be tempted to make the huge mistake of attempting to whip up enthusiasm yet again for Green Jobs. (In the wake of the collapse just last week of the heavily-government-subsidized and heavily-Obama-promoted Solyndra Company, and of at least two other companies that received large federal funds for Green Jobs, treading that dead ground again would merely reveal that he is entirely bereft of ideas.) The Administration ought to thank DrRich, and especially Dr. Charles, for this critically important advice. Encouraging poesy, instead of Green Jobs, would demonstrate the kind of new thinking we are all looking for from our President at this critical juncture.

At Dr. Malpani’s Blog, Dr. M. outlines his 3-step approach for helping his patients understand the intricate concepts of in-vitro fertilization. First, you describe how the thing is supposed to work when everything is functioning normally (the “thing” in this case being the human reproductive system). Then, you describe to the patient where the system is breaking down in his/her case. And finally, you describe the options available for mitigating the breakdown. Dr. Malpani’s system, which he points out is generalizable, is aimed at creating a consensus for action when faced with a complex problem.

DrRich will only remark that Dr. M’s system, which works well enough for problems based in human physiology, is proving pretty worthless for problems based in the more social sciences, such as economics. This is because of a fundamental disagreement, among the debaters, on how the economy is “supposed to work when everything is functioning normally.” Progressives and conservatives have very different ideas about this. So Dr. M’s approach, which requires both logic and a fundamental consensus on what constitutes “normal” behavior, is unsuitable to non-physiologic systems.

Dr. Val at Better Health posts a recent interview with Dr. Dori Carlson, president of the American Optometric Association, regarding the importance of screening children for subtle but significant vision problems. (Dr. Val and Dr. Dori are referring here to the kinds of vision problems that involve optics, and not the kind suffered by our political leaders.) The type of gross vision screening which is conducted by most schools misses the majority of these vision problems in children, and those undetected vision problems not infrequently lead to impaired learning. Also, they often lead to misdiagnoses and inappropriate treatment, likely including the misdiagnosis of ADHD. (Missed vision problems constitute only one of the causes for the explosion in ADHD diagnoses in recent years. A more common cause, in our overly-feminized schools, is being a boy. Indeed, as nearly as DrRich can tell, being a boy today is a disease; they have drugs for it and everything.) In any case, if you are a parent of a school-aged child, you should strongly consider having your child’s vision checked by an ophthalmologist or optometrist – especially if somebody wants to put him on Ritalin.

Henry Stern at InsureBlog tells us the good news and bad news about a new study related to heart attacks. He notes that heart attack victims are receiving definitive therapy in American hospitals much more quickly than they were just a few years ago. And when you are having a heart attack, minutes count – the longer that coronary artery is occluded, the more permanent damage is done to your heart, and the higher your odds of death or disability. So the diminished delay to treatment is good news. As usual, though, there is bad news attached. DrRich, always the sunny optimist, does not wish to repeat the bad news. You can go to the InsureBlog to read it for yourself.

The ACP Internist reports a study showing that 80% of today’s doctors look up on-line information in front of their patients. DrRich, who admits to being an Old Fart, does not find this surprising, since young physicians these days are, well, young. And young people are on-line all of the time, reporting their every trivial thought and mundane action instantaneously to the Cloud. (If Andy Warhol were alive today he’d be talking about our 15 minutes of anonymity.) But you don’t have to be a young doctor to take up these new habits. It appears from this new survey that doctors of all age groups have ritualistically placed an LCD screen between themselves and their patients. In so doing, they have awarded to those distant, expert panels – the ones spinning out all those guidelines, pay-for-performance checklists, marching orders, &c – their appropriate and rightful physical position, that is, directly interposed between doctor and patient. This is more than mere symbolism, but the symbolism is delicious.

But, dear reader, please do not be too critical of today’s doctors. If you yourself were a savvy modern physician, realizing that you could go to jail if you do what you think is medically appropriate before checking with the Authorities to find out if it is also allowable, you’d have a computer screen in front of your face too, and you’d be looking stuff up in front of your patients the entire time they were blathering on about their symptoms or whatever. DrRich worries for the 20% of doctors (likely, his fellow Old Farts) who haven’t “gotten it” yet.

Beth Gainer at Calling the Shots makes an important observation about the two classic narratives to which all victims of breast cancer are assigned – the narrative of the triumphant hero, and the narrative of the courageous and noble victim. Ms. Gainer’s observation is that most women with breast cancer do not fit either of these prescribed narratives. Many women are thus left feeling guilty or diminished when they find that their experience is not meeting with society’s expectations. Ms. Gainer is absolutely correct, and indeed, her observation is generalizable. The same thing occurs whenever society’s designated narrative-makers assign a range of permissible attitudes, thoughts and behaviors to any defined group. Mercy on any member of the group who falls outside those designated norms.

David E. Williams at the venerable Health Business Blog addresses the question of how we – society – will cope with the next big trend in the drug industry – the development of “niche” drugs, drugs that are suitable for only a relatively small number of patients and which, therefore, are exceedingly expensive to develop and market. David goes directly to the real question – the problem of niche drugs makes the issue of healthcare rationing unavoidable.

So far, of course, we are doing our healthcare rationing covertly, and in the case of niche drugs that usually means interpreting clinical results in such a way as to minimize their potential benefits. We do this by saying that Drug X “only increases survival by 4 months,” and ignoring the fact that “4 months” is an average value, and that while many patients have no benefit at all, a non-negligible minority may live a lot longer. The question, “Is it worth $50,000 for only four more months of life?” is different from the question, “Is it worth $50,000 to have a realistic shot at living several extra years?” Covert rationing causes us to frame the question in such a way that the answer to any question beginning with “Is it worth. . .” is always, “no.”

At the Road to Hellth, Douglas Perednia, one of the best analysts of health policy writing today, looks at the rationale for the onerous penalties which are required under Obamacare for hospitals whose patients are readmitted at higher than the average readmission rates. Perednia describes the bogus math which the Feds are apparently using to determine what appropriate readmission rates ought to be – and points out the irony of requiring doctors to behave in an “evidence-based” fashion, while the Feds themselves are using frivolous statistics to dole out the equivalent of the NCAA Death Penalty to our hospitals.

Steven Seay, PhD discusses what ought to be second nature to any clinician – applying the principles of the scientific method to clinical practice. That is: gather the necessary data to formulate an hypothesis; institute therapy based on that hypothesis; measure the results of that therapy; revise the hypothesis to reflect this new data; repeat as necessary. This is the way clinical practice should be done. DrRich is happy to learn that it is still apparently OK for clinical psychologists to function in this manner. For physicians, especially PCPs, the scientific method has become forcibly compressed to: make a diagnosis; treat according to the guidelines. While the patient might not do so well with this new method, the physician will be OK, since “quality” will be measured according to one’s compliance with the guidelines. Measuring the actual results of the treatment, of course, would only lead to trouble, and in most cases will be avoided.

James Gault, MD, of the blog Retired Doc’s Thoughts, is a long-time champion of classical medical ethics (as opposed to the New Age medical ethics now formally espoused by all the major professional organizations).  As such, Dr. Gault often deconstructs arguments being published by modern medical ethicists supporting these New Age ethics, which require doctors to act for the benefit of the collective rather than for the benefit of their individual patients. In this post, Dr. Gault gives a very effective what-for to Professor Fuchs of Stanford, who, once again, has published a paper advancing the bankrupt argument that what’s good for the collective is necessarily good for the individual. These kinds of vapid arguments may fool the Whippersnappers, but they’re not fooling us Old Farts.

The ACP Hospitalist notes that, according to the Institute for Safe Medication Practices, a “grey market” is developing for life-saving medications that have been in severe short supply for the past few years. A grey market, DrRich thinks, is like a black market, but less illegal – though it is possible they are referring to Old Farts who are merchants. In any case, the ISMP says the grey market is price-gouging hospitals that need those important drugs, and have nowhere else to buy them. The solution, according to the ISMP, is (among other things) to empower the FDA to manage drug shortages and tighten regulations for drug distribution.

The growing, widespread shortage of important medications is indeed a bad problem. We should look for a solution to this problem. Shortages of any product occur when it costs companies more to make the product than they can get for it in the marketplace. Onerous regulatory policies by the FDA which, in the name of product safety, have greatly increased the cost of doing business for pharmaceutical companies, along with recent de facto price controls on generic drugs, have combined to make it economically unfeasible for drug companies to expend large resources to manufacture these drugs. It seems doubtful that piling on even more regulations will improve the situation. And attacking the grey markets will simply drive them further into the dark (since black markets are nature’s way of providing a product when governments act to limit it). Given the expected 500,000 pages of new regulations being conjured up out of the Obamacare legislation, drug shortages are merely the first of many critical medical shortages we will be seeing in the coming years. So it will be instructive to watch how our leaders handle this problem.

In any case, from the job-creation standpoint, DrRich believes there will be many employment opportunities in coming years in sundry black markets related to healthcare. Many skills will be needed, some of which should be quite exciting!

At the Prepared Patient Forum, Trudy Lieberman writes a post entitled “Health Insurance, Meet the Jolly Green Giant,” in which she discusses the new, patient-friendly labels that are supposed to accompany health insurance policies under Obamacare beginning no later than 2014. The labels sound like a good idea, but as Ms. Lieberman points out, there will be problems. For instance, for the Feds to mandate transparency in labeling is unlikely to be all that helpful when, at the same time, they often mandate utter secrecy on the part of providers (for instance, in creating severe anti-trust penalties for doctors who reveal the fees they have negotiated with insurance carriers). But as always, results are far less important than simply meaning well.

Sharp Incisions, a blog written by a self-described “fledgling” medical student, has sent in an affecting post about scrubbing in on a unique surgical case – the harvesting of six vital organs for transplantation from a patient who has been declared brain dead. DrRich prays that Dr. Incisions will maintain for a long time the same sense of wonder and gratitude, expressed in this post, for the gift of life.

A medical student who blogs anonymously at the D.O.ctor Blog, describes her first experience participating in cardiopulmonary resuscitation when it actually counted. DrRich, who in his days as a cardiac electrophysiologist ran hundreds of these things, and who became convinced over the years that three people was the optimal number to run a “code,” admits to being a little taken aback by this student’s description of the event, which sounds like it must have been as complex to coordinate as a Busby Berkeley production number. No wonder she was a little astonished by her experience. DrRich supposes that this must be the new-style CPR mandated by some new guideline or other, and would not be surprised to learn later this week that CPR procedures requiring 15 participants is part of the President’s new Jobs Plan.

Speaking of sudden death, one of DrRich’s recurrent themes here on the CRB is that sudden death is a great boon to our healthcare system (since not only is sudden death itself very cheap, but also it tends to remove individuals who would otherwise continue collecting Social Security, and who tend to have expensive chronic heart disease), and that therefore the government will tend to stifle the prevention of sudden death any time it can. Accordingly, Dr. Wes tells us that the Feds are about to further limit the use of the Zoll wearable defibrillator. Doctors have taken to using this device in high-risk patients during the first month or so after a heart attack, since guidelines specify that ICDs (implantable defibrillators) must not be implanted during this interval. Since sudden death is particularly likely during that first month, the Zoll device is being used as a “bridge to ICD.” Obviously, sudden death being the healthcare system’s friend, this must not be permitted. And so, Dr. Wes points out, soon it will not be.

At the HealthAGEnda Blog of the John A. Hartford Foundation, Marcus Escobedo describes how his father is coping with the decisions that need to be made as he deals with recurrent prostate cancer. Helping elderly patients deal with health issues is the thrust of Mr. Escobedo’s work at Hartford, and his new personal experience, he tells us, drives home the point. Specifically, Escobedo works to assure that elderly patients are considered to be more than just the sum of their disease and their age. DrRich is sorry to have to point out that no less an expert on American healthcare than President Obama has explicitly disagreed with this approach, and on national television to boot. Perhaps when he said this the President was suffering under the influence of teleprompterpenia, and perhaps if he had an opportunity to meet with Mr. Escobedo over a beer in the Rose Garden, he would possibly begin to revise his position to one that is more compatible with the mission of the Harford Foundation. On behalf of America’s Old Farts, DrRich would certainly hope so.

Dr. Thomas Pane writes in the Business, Surgery & Medicine Blog about tantrums, specifically, the kind occasionally thrown by surgeons in the operating suite. His post carries an important Labor Day lesson for anyone who hopes to make a career in the medical field in the coming years, so pay attention:

Everyone can agree that throwing tantrums in the operating room is never a good thing, and that quite often, it is a very bad thing. But Dr. Pane points out that, counterproductive as tantrums often are, they are nonetheless not the worst possible way in which a surgeon can express his/her utter frustration at a bureaucracy that blithely conspires to disrupt surgical procedures at critical moments. He reminds us, once again, that the biggest handicap one can ever have when working in an environment in which bureaucratic mud has fouled every gear is: giving a sh*t. So, while Dr. Pane may or may not agree, here’s the lesson: If surgeons would simply adopt the apathetic, indifferent attitude that classically characterizes long-term survivors in work environments mired by bureaucracy, all would be well.

Jaqueline writes Laika’s MedLiblog, a blog dedicated to medical information science. She submits a post entitled, “PubMed’s Higher Sensitivity than OVID MEDLINE… & other Published Clichés,” in which she shows how medical researchers doing literature searches for, among other things, meta-analyses, will stumble upon various “anomalies” in their searches of the PubMed and OVID databases, and then write additional, CV-padding papers about those anomalies. Jaqueline points out that these so-called “anomalies” are actually well-documented “clichés,” which are well-known to information specialists and anyone else who is competent in doing comprehensive literature searches. In other words, Jaqueline has documented that these meta-analysis researchers are rank amateurs at doing the most critical step in conducting meta-analyses – searching the literature for all the appropriate published studies. DrRich has always mistrusted meta-analyses, and Jaqueline has helpfully identified yet another reason to justify such mistrust. He thanks Jaqueline, and whoever planted those database anomalies which allow us to identify potentially incompetent meta-analysis researchers.

Nicholas Fogelson of Academic OB/GYN writes about taking care of the dying Jehovah’s Witness patient, or rather, taking care of the Jehovah’s Witness patient whose illness is potentially curable but who is dying because he or she refuses to accept blood products. DrRich can attest to how very difficult it is for a doctor to respect a patient’s religion when doing so results in their death. Dr. Fogelson’s description of his evolving attitude regarding this dilemma is compelling.

Need to be uplifted after reading the above post? Read Jordan Grumet’s submission from his blog, In My Humble Opinion. It’s brief and beautifully written, and it reminds us that sometimes our efforts as doctors – which all too often seem futile – can pay off in unimagined ways.

Pranab at the Scepticemia blog points to a news story about a medical school in Mumbai selling seats (that is, entry to medical school) to the highest bidder. He strongly objects to this practice, even though he postulates that his objection will make some of his readers call him “a leftist commie” (which DrRich finds to be the most common kind). DrRich does not agree with Pranab’s (tongue-in-cheek) conclusion that it is America’s fault that Mumbai medical schools are selling seats. (It is actually only George Bush’s fault.) But DrRich does agree entirely that the practice itself is an abomination. Indeed, we can all agree that entry to any career which requires a high degree of skill, talent, and/or intelligence ought to depend on merit, and nothing but merit. Can we not? Good.

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DrRich will end by noting that he is finishing this Jobs! Jobs! Jobs! Edition of Grand Rounds during the waning moments of Labor Day, which causes him to fondly recall those long-ago days of yesteryear, when the U.S. still had plenty of steel mills and DrRich was a card-carrying member of the United Steelworkers of America, and the thought of attending medical school had not yet penetrated his still-empty head. And he recalls how, while he was working one day as a lowly laborer, a union boss came over to him to explain (after DrRich had complained about it) the utility of his spending three painful days moving a large pile of slag, employing only shovel-and-wheelbarrow technology, from one location to another – AND THEN BACK AGAIN.  Now, those were the days when we knew how to make jobs!

Say, whatever happened to those steel mills, anyway?

Everyone agrees that national spending on healthcare is on a trajectory to bankrupt America during the lifetimes of even Old Farts like DrRich. And therefore, most folks* agree that we ought to do something to reduce our national spending on healthcare.
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*The reason it’s only “most folks” who agree is that, apparently, some folks are still partial to the Cloward-Piven strategy, and continuing to spend on healthcare as we are doing today is the quickest and surest way to get there.
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Unfortunately, our national “discussion” on how to achieve this reduction in healthcare spending has devolved into a spectacle of accusations and counter-accusations, vituperation, abuse, and scurrility. Accordingly, not much useful has so far been achieved. Worse, the back-and-forth contumelies lobbed by the various interest groups in this national discussion have created a general sense among the public that the problem is so confused and chaotic, so rifled by conflicts of interest, and so very complex, as to be fundamentally unsolvable.

This general sense of despair is entirely unnecessary. DrRich is here to assure his readers that the problem of healthcare spending is not only solvable, but that it is destined to be solved – and within the lifetimes of many of us.

Furthermore, there are four ways (and only four ways) in which this inevitable reduction in healthcare spending can be achieved. By knowing these four methods of solving the problem, it is entirely possible – as we listen to all the debating, fighting, and reciprocal castigations, aspersions, distortions and lies being cast by and amongst the various interest groups – to understand which method is actually being espoused by which parties. If you happen to be partial to one method over another, this kind of knowledge can help you determine to whom you should offer your support.

And so, in the way of providing yet another remarkable service to his readers, DrRich is pleased to describe the four ways to reduce healthcare spending.

Method One: Make all healthcare spending the responsibility of the individual.

This is the method by which most of mankind has paid for healthcare for all but a few decades of the millions of years we have graced (or plagued) the planet: If you want or need healthcare (and if it exists), simply pay for it yourself. Proponents of this method offer two general arguments to support their position – an ethical one, and a practical one.

It is fundamentally unethical to insist that an individual’s healthcare services must be provided by others – claiming that healthcare is somehow intrinsically different from any other product or service which the individual may wish to acquire (such as food, clothing, housing, and iPADs) – because insisting on such a thing will place an unjustifiable burden on one’s fellows. Much of a person’s health (and therefore, of a person’s healthcare needs) is determined by lifestyle choices, so it is only right and proper for the individual to bear responsibility for those choices. Demanding that one’s fellow citizens take that responsibility for such personal choices is fundamentally unethical – and requiring them to do so will inevitably lead to tyranny by some Central Authority.

Method One also holds that, by returning the purchase of healthcare back into the realm of actual market forces, the laws of supply and demand will determine which services are actually needed, and what the rightful price for those services ought to be. So from a practical standpoint, Method One will at last recruit the efficiencies of the marketplace into the healthcare system, and bring the cost of healthcare services down to a level which individuals can actually afford. (And if people can’t or don’t want to pay for healthcare services, they are more likely to begin making lifestyle choices that will lower their odds of having to do so.) But whether or not individuals can afford medical services, at least the spending on those services will no longer be the burden of society – and the fiscal doom we now face will be cured.

Opponents of Method One point out that, inevitably, there will be individuals – and likely many, many individuals – who simply will not be able to afford to pay for healthcare services which are needed, and which are readily available for a price, and will therefore suffer preventable pain, disability, and death. Without some kind of public support for healthcare, heart-rending tragedies will abound, our civilization will become coarsened, anger will build, and insurrection will become a constant threat.

Method Two: Make all healthcare spending the responsibility of a Central Authority.

Method Two holds that, for straightforward ethical reasons, healthcare is a fundamental right; that whether one receives a healthcare service – a service that can relieve pain or prevent disability or death – ought not to depend on one’s ability to pay, but that healthcare services ought to be equally available to everyone. The only way to achieve this goal is to collectivize and centralize healthcare decisions and healthcare spending.

For proponents of Method Two, healthcare services are indeed fundamentally different from all other human needs – food, clothing, etc. – since the kind and the amount of healthcare services one needs are much less a matter of individual choice, but are foisted upon one by fate. Burdening individuals with the need to pay for such arbitrary and uncontrollable costs is not only unethical, but destabilizing.

Requiring individuals to pay for their own healthcare is destabilizing because, if a person’s lifetime of work and saving can be wiped out in an instant by an unexpected illness, people will be much less willing to work hard, take risks, and otherwise engage in the economic activities that drive our society. “Healthcare security,” which can only be provided by collective efforts, is thus necessary to a robust and sustainable civilization.

The methods by which healthcare costs can be controlled under a centralized system are straightforward. Obamacare, for instance, does so by explicitly empowering a (nearly) all-powerful Independent Payment Advisory Board (IPAB) with all macro-level healthcare spending decisions. Furthermore, “guidelines” promulgated by various other expert panels will control spending at a more granular level, by determining which specific services doctors will be permitted to offer to which patients, and under what circumstances. Doctors will be strictly held, under the threat of criminal prosecution, to these guidelines. Finally, recognizing implicitly that many healthcare needs are indeed determined by individual lifestyle choices rather than purely by chance, public health experts will advance enforceable policies that will determine what and how much we eat, when and how long we sleep, what products we acquire and how we use them, and what activities we are permitted to perform where. (The public health experts are off to a very good start in this effort!) If everyone within the healthcare system (and in our society) will simply follow the multitudinous directives laid out by the legions of sanctified experts, costs will at last be contained, and all will be well.

Regular readers will understand that there is no need for DrRich to reiterate in any detail here the arguments that have been raised by opponents of Method Two. These arguments can be summarized simply as follows: Method Two inevitably leads to tyranny.

Method Three: Provide strictly limited public support for basic healthcare services, with individuals responsible for the remainder.

Method Three attempts to combine the benefits of Methods One and Two, while avoiding their major disadvantages. Method Three recognizes that paying for all of one’s own healthcare is beyond the means of many individuals, and that therefore a modern, civil society ought to provide at least some healthcare to at least some of its citizens. At the same time, Method Three recognizes that the public funding of all healthcare is beyond the means of society, will inevitably lead to ruin, and that (both for these practical reasons and for ethical reasons) individuals ought to be responsible for paying for at least some of their own healthcare.

Numerous configurations are possible under Method Three. The key to controlling costs is that the dollars which society will spend on healthcare for individuals must be strictly defined and strictly limited, and cannot be open-ended. Method Three ought to assure that individuals will have ready access to, and the means to pay for, basic healthcare services, and that the chances of being financially ruined by a catastrophic illness are very low, but at the same time that most individuals should not and cannot rely entirely on public funding for their healthcare.

Examples of “Method Three” configurations include the detailed three-tiered solution that DrRich proposed in his book; the Ryan plan, which would limit Medicare expenditures by providing seniors with a fixed amount of money – on a means-tested sliding scale – with which to purchase their health insurance of choice; and, at least arguably, the original conception of Medicare, in which it was at least legal, if not expected, for seniors to pay for additional, non-covered medical services with their own funds (an option which is now very difficult, and often illegal).

How is the battle shaping up?

As DrRich sees it, Method One is simply a non-starter. For all practical purposes, and for good or bad, we moved irreversibly beyond a purely self-pay healthcare system over 60 years ago. So the real battle is between Method Two and Method Three. The feud between these two methods is going to be a bloody one.

The key difference between these two methods – both practically and philosophically – is whether individuals will be permitted to pay for at least some of their own healthcare with their own money. For reasons DrRich has laid out previously, it is imperative under Method Two that all healthcare decisions and all healthcare spending be centralized. There can be no compromise on this.  The moment a compromise is made, we will inevitably wind up under a Method Three healthcare system.

Proponents of Method Two do not like DrRich (and have said so many times), because he has concluded (and often repeats) that, viewed objectively, the only logical reason these people fight so hard to keep individuals from being required (or even permitted) to assume at least some financial responsibility for their own healthcare, is that their actual prime objective must be something other than to fix the healthcare system and control healthcare expenditures. Rather, their actual prime objective must be, and can only be, to centralize the control of our society. The healthcare fiscal crisis is merely the most expedient vehicle to achieve this prime objective. (Progressives mean well, as DrRich has said many times, but their plan for a perfect society is always based on the need for all of us in the great unwashed masses to subsume our individual prerogatives in favor of the dictates of the enlightened leadership. Unfortunately, history teaches us that this plan never works out well.)

If this battle is ever resolved, therefore, it will hinge on whether individual Americans retain the legal right to purchase healthcare services with their own money. DrRich admits that this conclusion, regarding the essence of our ongoing healthcare debate, is not one which has been remarked by many other commentators on healthcare policy. It is, nonetheless, the case. An objective observer who pays close attention to the machinations of the nameless bureaucrats who are currently writing the rules and regulations under which Obamacare will finally be prosecuted will see that it is so.

What about Method Four?

There is little reason to spend much time discussing the fourth and final method for controlling healthcare expenditures. Nobody is a proponent of this method, so nobody discusses it. However, Method Four, at this moment, seems to be the most likely outcome. Indeed, at this moment it is our default method of choice.

Method Four is formulated as follows: Our skyrocketing healthcare expenditures are the chief driver of our national debt. Our national debt burden, unless we get control of it by controlling healthcare expenditures, will inevitably destroy our civil society. At the same time, our modern, sophisticated and very expensive healthcare system utterly requires a complex, modern, organized, high-tech society in which to function.

Therefore, our skyrocketing healthcare expenditures ultimately provides its own cure. Once society collapses, “healthcare services” will revert back to the roots-and-poultices methodologies that served mankind so well for millions of years. And healthcare, as well as other modern geegaws like cable TV and the Internet, will no longer be a fundamental human right, but will become a mere afterthought (if a thought at all) in a more primitive kind of society where life is nasty, brutish and short.

So, not to worry.

In response to DrRich’s recent post on good debt vs. bad debt, Liz writes:

Is the survival of the individual, after consuming healthcare, necessarily neutral to our national economic health? On the one hand, if an individual is saved from death by consuming healthcare and goes on to be very productive in life, then that healthcare would have been a good investment. On the other hand, if someone else is saved by doctors, only to go on to require more and more medical care without contributing anything to the collective, then the individual’s survival has a negative impact on the nation’s economic health. . . . Some people will argue that keeping people healthy is a good investment for our country.

This comment was triggered by DrRich’s premise (modeled after Alexander Hamilton) that for the federal government to acquire certain kinds of debt – say, borrowing money to build a new hydroelectric plant that will supply electricity to a large region of the country and thus enable sustained economic expansion – is truly a positive investment for future generations, and is thus justifiable; while aquiring certain other kinds of debt – for instance, purchasing goods or services for individuals, which the individuals then consume in the normal course of their lives – leaves nothing for future generations aside from the accumulated debt, and thus is fundamentally unjustifiable.

Liz rightly points out that not all the debt we accumulate to pay for Americans’ healthcare is of the latter variety. It is certainly true, for instance, that going into federal debt to purchase a liver transplant for Steve Jobs would end up being a positive investment over time. There are certainly many people less notorious than Mr. Jobs – possibly millions – who might also fit into this “good investment” category.

So, Liz’ comment implies, it may be that increasing the federal debt to buy healthcare for Americans – at least some Americans if not all* – actually constitutes a good investment, and therefore good debt.

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* Progressives, despite their protestations to the contrary, have actually given a lot of thought to which individuals should receive priority for healthcare services once they have the single-payer (centrally controlled) system they have long desired. They have occasionally, in unguarded moments, opined publicly on which sorts of Americans should receive expensive healthcare services and which should not. Their proposed rationing methodology indeed shunts healthcare services to those individuals who are judged to be “productive” by the Central Authority.  In their 100-year history Progressives have never been slow to pass harsh judgment on the worthiness of various groups or individuals, and there is no sign that they will behave any differently going forward. (DrRich, even if he were not an old fart, fears he would not wind up in the Central Authority’s “good” list.)
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There are certainly examples of Americans happily agreeing to pay collectively for services consumed by individuals, because doing so is a good investment for the future. Chief among these is public education. Unarguably, an educated public is critical to continued economic growth and development, so (leaving aside for now the actual effectiveness of public education) paying collectively to educate all American children unquestionably benefits all current and future Americans.

Some would even argue – and DrRich would agree – that maintaining a certain level of health among the population is just as important to continued economic growth as is public education, and so paying collectively to achieve such a thing is equally a good investment. This is why DrRich fully supports many collective efforts to assure public health, such as assuring clean water, keeping air pollution to a minimum, and maintaining a healthy and safe food supply.

But DrRich’s thinking on the matter is even more radical than that. DrRich believes that it is indeed reasonable, and likely a good investment for the future, to use collective funds to pay for some of the healthcare consumed by individual Americans.  If Americans know that, no matter what their socioeconomic status, they are unlikely to become financially ruined because of some expensive medical catastrophe, they will be more willing to take the risks one traditionally takes (under a vibrant capitalist system) to grow one’s own wealth – and the overall economy.

So, to some extent, DrRich believes that collective spending on the healthcare of individual Americans can indeed be an investment for the future, just as President Obama says.

But the key phrase here is “to some extent.”  That is, we cannot furnish every bit of desirable healthcare for every individual, because that way lies ruin. We must set limits. DrRich has a simple rule for determining when our collective spending on healthcare is “too much.”  Our collective spending on healthcare is too much when the level of debt we’re accumulating to pay for healthcare is sufficient to threaten the economic destruction of our society. Triggering societal collapse, DrRich thinks, completely negates any “investment value” we might obtain by purchasing healthcare for individuals.

The healthcare system we have today, and the one we will have under Obamacare (at least, the kind of Obamacare that Progressives will admit to at this point), exceed even this very modest definition of “too much.”

DrRich has proposed a structure for an American healthcare system that would offer healthcare to each individual, without accumulating an unsustainable debt, and he has described it in detail in his book. Simply put, it is a 3-tiered system. In Tier 1, individuals would pay for (say) the first $3000 per year of their own healthcare expenses. Tier 1 spending would be funded from a tax-deductible, self-funded, self-owned Health Savings Account. Individuals below a certain income level would have their HSA funded by the government. Tier 2 would be a government-funded universal basic health plan, under which most additional healthcare expenses would be covered.  However, in the interest of keeping federal debt to a manageable level, Tier 2 would function under an open, completely transparent system of rationing. While most things would be paid for, some would not. The rationing system would allow the government to control how much it spends on healthcare each year, thus avoiding the crushing debt burden we are accumulating today. Tier 3 would be an optional, self-funded health insurance product that would cover extraordinary expenses that exceed the $3000 per-year individual limit, and are not covered under the Tier 2 rationing plan. Tier 3 would return the health insurance industry to the business of selling an actual insurance product (that is, a product that prevents individuals from financial ruin due to relatively unlikely future events), instead of whatever it is they’re selling today.*

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* Thus, DrRich’s plan would give the insurance industry what it desperately needs – a new business model – without having to sell out to the Central Authority and survive under the diminished status of public utility.
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Conservatives hate DrRich’s system because it includes a universal health plan. Progressives hate DrRich’s system because it does not offer enough centralized control, and indeed encourages (even demands) that individuals take chief responsibility for their own healthcare. So DrRich does not reiterate his plan for healthcare reform because he thinks it is even remotely possible that such a thing will ever be adopted, but simply to illustrate that it is indeed possible, with just a little effort, to imagine a healthcare system that actually meets the goals that Progressives and conservatives will admit to in public – and that honors the worthiness and the potential of each individual.

1) Obamacare might be repealed.
2) Obamacare might be found unconstitutional.
3) If Obamacare is permitted to proceed into its full glory, it shouldn’t be long before it leads to social upheaval either by: a) exploding the federal deficit far beyond even what we’re seeing today; or b) alarming a critical mass of Americans regarding the new, oppressive powers which the new law grants to the federal government.

If 1 or 2, the process by which our nation will re-address healthcare reform may look much like the contentious, but deliberative, processes we have used in the past to reform certain aspects of our society. If 3, the process may look a lot more like Egypt.

In any case I think there is a reasonable chance that, in the next few years, we may be looking for a completely new way to reform our healthcare system, one that resembles neither Obamcare, nor the alternate and rather tepid “solutions” that have been proposed by the Republican leadership.

When that day comes, you will be very glad you took the time to read Douglas Perednia’s new book, Overhauling America’s Healthcare Machine – Stop the Bleeding and Save Trillions.

Perednia, something of a polymath, is an internal medicine specialist as well as a dermatologist, an NIH researcher, a writer, and an expert in telemedicine and medical informatics (he is a professor of this latter discipline). While he has founded and directed non-profit organizations, he is also an entrepreneur (which explains how he has become “New Zealand’s sole domestic source of boiler cleaner and glue for beer bottle labels”). He admits also to being a tap dancer (not that there’s anything wrong with that). And, as anyone will know who reads his excellent blog, Road To Hellth, he also knows a lot about the healthcare system.

Perednia’s book is a true tour de force – but don’t let that frighten you away. The author’s writing style is clear and conversational, easy to follow and entertaining to read.

In this style, he tells you everything.

Perednia does not pretend that American healthcare isn’t in dire need of the very kind of fundamental change that President Obama says he wants, nor does he pretend that a little insurance reform will do the trick. The healthcare system, he suggests, is on its last legs. It is a machine that is wearing out and bogging down, and it needs to be completely overhauled.

The healthcare machine is far more complex than it ought or needs to be. It is burdened by all manner of extraneous flywheels, gears, and gewgaws that were glommed on during its long history to please one long-forgotten constituency or another, that do nothing useful, but that consume a lot of fuel and deposit a lot of grime. The healthcare machine’s great creaking clockwork grinds away against all this unnecessary friction and accumulated grunge, and for all its strenuous efforts produces an ever-smaller amount of useful work. What this machine needs is more than some bright new attachments and smarter operators to oversee its churnings. It needs to be torn down and rebuilt.

Perednia does not pull his punches. He starts by showing that the American healthcare system, when its output is analyzed objectively and soberly, does not produce nearly as much good as its present apologists suggest. It certainly does not produce very much good in relation to all the money we spend on it. He then moves on to analyze the roles all the big players have within the healthcare system in producing all this waste. He amply demonstrates how the doctors, the hospitals, the insurers, the government (and, yes, the patients), behaving in a manner that is entirely consistent with the incentives the system has provided for them, with no especial evil in their hearts, and with no more than the natural, baseline amount of greed and self-interest that accompanies any human enterprise, operate in a grotesque ballet of waste and excess. He shows how the healthcare machine has reached the point where it simply cannot go much further, and that, like it or not, we’re going to have to do something about it. (Along the way, Perednia clearly demonstrates how Obamacare, far from representing any kind of fundamental departure, simply exaggerates the pathology.)

The strongest part of this book, however, deals with how to fix all this. Perednia begins by establishing what almost anyone would agree ought to be the goals of the American healthcare system – it must deliver effective and efficient healthcare services in a manner whose fairness to all Americans is commensurate with the contributions all American make to it, and it must be financially sustainable – at least to the point that its cost does not drive us to societal collapse. He then outlines a scheme that can achieve these goals.

I would be less than forthcoming if I did not mention that the broad outline of Perednia’s solution, as he graciously acknowledges, derives from my own book. That outline looks like this:

He proposes a 3-tiered healthcare system. The bottom tier, Tier 1, consists of self-pay healthcare. All individuals would be expected to pay a certain amount each year toward their own healthcare, say $2000 per individual, or $4000 per family. The funds for Tier 1 could reside in a Health Savings Account, which the individual would own. People with low incomes would have HSAs funded by the government. But everyone has the opportunity to own an HSA, and everyone controls the first $2000 of spending on their own healthcare (and keeps what money is not spent).

Once the individual exhausts their annual $2000 limit, their healthcare would default to a publicly-funded Universal Health Insurance Plan (Tier 2). The universal health plan – which would cover every American, even members of Congress – would operate under a system of open healthcare rationing, for the purpose of keeping public spending on healthcare on a reasonable budget. Perednia spells out the details on how such open rationing could be accomplished. Obviously, establishing any system for openly rationing healthcare would be a very difficult and exceedingly painful process. It seems very likely that only after experiencing great gouts of pain from our current healthcare system could we Americans be enticed to tackle such a thing. But Perednia (and I) postulate that such a circumstance may become manifest in the very foreseeable future.

Tier 3 is a completely voluntary, self-funded insurance product. Here, the health insurance industry would offer various levels of additional health insurance to people who want it, which will pay for services not covered under the open rationing in Tier 2. Health insurance in Tier 3 would begin to look like an actual insurance product (i.e., one that protects individuals against unforeseen, potentially catastrophic expenses), instead of the soup-to-nuts coverage of everyone’s heart’s desire that now passes for health “insurance.”

Again, this is just an outline. While my book did not take it much farther than this, Perednia takes his solution to the healthcare problem several steps beyond, and provides a very comprehensive plan. He discusses specifics of insurance reform, physician reimbursement, paying for goods and services, physician credentialing, government regulation, malpractice reform, addressing fraud and abuse, implementing electronic medical records that actually help efficient patient care (a particularly strong section of the book), and assuring that innovations in healthcare are encouraged. If you really want to know how to fix American healthcare, it’s all here.

Once Omamacare is repealed or declared unconstitutional, or once it goes forward in tact to accelerate the final implosion of our already-near-terminal healthcare system, smart people will find themselves looking for new ideas upon which to re-build American healthcare. Amidst all the cacophony about healthcare reform, however, there are really only very a few voices that are offering truly novel solutions. Doug Perednia has thrust himself to the front of that short list of visionaries with Overhauling America’s Healthcare Machine.

Please read this book, so that when the time comes you can tell your Congressperson (or perhaps by that point, your local Commissar) about it.

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Overhauling America’s Healthcare Machine is available in all bookstores, and at Amazon.

While DrRich is a conservative American, and has made plain the difficulties he has with the Progressive program in general and with Progressive healthcare reform in particular, at times he is forced to admit that, on occasion, the Progressive way of looking at the world has certain merits. And as DrRich contemplates a question that has been bothering him lately, a question that no doubt plagues many American physicians who (unlike DrRich) are still toiling away in the trenches, he finds that this is one such occasion.

That question is: Just who are the people writing all those clinical guidelines – the  “guidelines” physicians are now expected to follow in every particular in every case, on pain of massive fines, loss of career, and/or incarceration?

DrRich is quick to say that the act of creating clinical guidelines is not inherently evil, and indeed, back in the day when guidelines were merely guidelines (instead of edicts or directives that must be obeyed to the last letter), creating clinical guidelines was a rather noble thing to do.

But today, we have physicians clamoring to become GOD panelists (Government Operatives Deliberating). These aristocrats of medicine will render the rules by which their more inferior fellow physicians, the ones who have actual contact with patients, will live or die. Clearly positions of such authority will be very desirable, and so, as one might predict, they are being vigorously pursued. And we are seeing candidates audition for these panels with efforts ranging from amateurish to ruthless. It puts one in mind of the early-season contestants on “American Idol.”

We see them vociferously extolling, in every public venue they can find, the idea of “fly by wire” medicine, whereby every decision physicians make will be determined not at the bedside but by the best and the brightest experts, acting at a distance. The experts will distribute rules of action based on only the best scientific evidence (“best” being determined by those selfsame experts). The directives they hand down will be models of actionable simplicity,spelled out so unambiguously that even doctors born, raised, and trained in the Midwest or the South will be able to follow them.  (And if the doctors refuse to cooperate sufficiently, non-physician medical professionals will be able to do the job.) We see them writing scientific papers that spin the evidence in such a way as to generate conclusions which will be soothing to the Central Authority. We see them editing medical journals in order to make certain that the correct conclusions are published, and the incorrect ones are not. We see them taking control of professional organizations, and using their positions to promulgate changes in medical ethics that advance the Borg-ification of medicine, and to formally endorse Obamacare on behalf of American physicians who, for the most part, were against doing so.

These people have gained great prominence within our healthcare system, and practicing physicians will be dealing with them and the consequences of their actions for many years to come. While the natural impulse of us typical American doctors may be to simply marvel at the wonder of it all, shake our heads resignedly, and go about our increasingly distressing business, it may behoove us to take a closer look at these individuals, to attempt to understand them a little better. After all, their activities in the near future promise to greatly impact our lives, our fortunes, and our sacred honor.

So – who are they, anyway?

This, dear reader, is where the Progressive mode of thought comes in handy. DrRich refers, of course, to the Progressive doctrine of Diversity.

Diversity, for those who pretend not to know, is perhaps the chief mechanism by which Progressives attempt to control the behavior of the population.

Recall that the Progressive program is to create the perfect society. The Progressive elite know just how to do this, of course, but individuals within every population throughout human history have insisted upon acting in their own self-interest, which is counterproductive to the collective goal. In past efforts to perfect human societies, such individual recalcitrance has been dealt with by means of concentration camps and pogroms and the like. “Diversity,” we all should admit, is a much kinder and gentler approach to curing the problem of individualism.

Specifically, the doctrine of Diversity defines the range of permissible behaviors and thoughts for a given group of people within a society. The numerous celebrations of Diversity we see all around us invariably turn out to be strategies to reinforce those allowable ranges of thought and behavior. In this way, members of a particular group who begin behaving and thinking outside the allowable range can be quickly identified and dealt with, either through correction (which brings them back into the group), or through vilification (which marginalizes them). It is easy to become confused about this, since classically “diversity” means something other than “conformity.”  (As a general rule, if you want to know what Progressives are really up to, listen to what they say and then look to see if their deeds are actually working toward the opposite thing.  DrRich thinks that much of the time you will find that they are.)

In any case, while in general DrRich does not approve of Diversity as it is being practiced today, he finds that the concept might be useful in attempting to answer the question at hand.

Specifically, DrRich refers to his theory that physicians (like any humans) tend to end up in careers that best suit their underlying personalities and proclivities, and so physicians in a given specialty will tend to think and behave like other physicians within that specialty, and unlike physicians in other specialties. If this theory has any merit (and let us call it the Diversity Theory of Physicians), it will allow us to make some generalizations about the characteristics of individuals who have chosen specific kinds of medical careers. DrRich stresses that he is aiming to make generalizations only, and while those generalizations might help enlighten us to a modest degree regarding, say, what sort of physician will end up on the GOD panels, they can tell us nothing about particular individuals.

With that annoying disclaimer out of the way, let us examine some ways in which the DTP reveals Truth. An obvious example is the specialty of psychiatry, which tends to attract doctors who are, perhaps subliminally, concerned that they are just a little crazy themselves. As it happens, it often turns out they are correct. In DrRich’s experience, and in the experience of just about anyone who has encountered more than a handful of shrinks, these fine physicians, on average, display an astonishing degree of off-the-wall psychopathology. (Not that there’s anything wrong with that.)

Emergency room doctors have short attention spans and are afraid of commitment.

Endocrinologists get their jollies by sitting alone in cramped offices, parsing tremendous volumes of laboratory data from blood tests, which they claim reflect moment-to-moment variations in hormone levels, and from this arcane evidence are able to parse out (so they say) subtle glandular difficulties. If endocrinologists were not physicians they would be accountants; the more aggressive endocrinologists (who are identifiable by the dirty glance they give you if you happen to interrupt their lonely cogitations) might be forensic accountants. (How anybody could specialize in any organ that just sits there, perhaps secreting various invisible substances, but otherwise not doing anything whatsoever,  DrRich will never understand.)

Orthopedic surgeons are former jocks, or wish they were, and the ones who end up replacing hips in old ladies instead of patrolling the sidelines at college football games are often very frustrated individuals.

Party animals who manage to gain entrance to medical school often end up as anesthesiologists.

Cardiologists like to envision themselves (and would like others to envision them) as living on the edge. After all, they put catheters into damaged coronary arteries in patients on the brink of heart attacks, and, through their skillful manipulations, open those arteries and save lives. They are the extreme sportsmen of medicine, so they believe. But really, their jobs are ones of relative security, predictability and instant gratification. What they do in the cath lab actually is pretty rote, and it provides them with immediate, concrete results. They can even show the “before” and “after” pictures to the person they just saved, who will then heap praise and shed tears of gratitude upon them. But any time fixing a particular artery looks a little too risky, they call a cardiac surgeon right away. This pattern of behavior suggests to DrRich that their aggressive personnas and glory-seeking activities are actually masking an underlying insecurity.

It would not be fair of DrRich to psychoanalyze all these other specialists – who have done nothing to provoke him – without also doing the same for electrophysiologists. All electrophysiologists started out as cardiologists, of course, so they have that going for them. But to really understand electrophysiologists, one must invoke the principle of sublimation. To sublimate is to channel an underlying negative tendency to some activity that partially gratifies that tendency, but that is considered worthwhile by society. So, for instance, people with a tendency toward pyromania may become volunteer firefighters. People with sadistic tendencies may become prison guards. Foot fetishists can become shoe salesmen. Compulsive liars can become novelists.

Who, then, become electrophysiologists?

Back in the 1980s and 1990s, when DrRich was practicing, what electrophysiologists mainly did was to try to prevent sudden death in patients who had a high risk of dying suddenly from cardiac arrhythmias. And in order to find the optimal therapy for these patients, it was necessary to induce, intentionally and repeatedly, cardiac arrests under controlled conditions. This was done in an effort to find an antiarrhythmic drug that would prevent the induction of cardiac arrest. This behavior we euphemistically called “serial drug testing.”  Fortunately, this procedure is no longer necessary, since the implantable defibrillator has been perfected and is now widely available for high-risk patients (if you can get it paid for).

While it has been widely remarked that those early-day electrophysiologists were a very strange group indeed, most of us who did this serial drug testing ended up successfully absorbed into normal society, and today (as far as DrRich can tell) we are for the most part generally pretty harmless. But DrRich sometimes finds himself wondering what might have become of some of us (some in particular more than others) if we had not had this remarkable opportunity to sublimate what one might speculate to be some rather unpleasant tendencies. And what is to become of that young person today who has whatever those unfortunate tendencies might be, and who, 30 years ago, might have found release as an electrophysiologist? One must not think too deeply about this.

Let us now turn our attention to those would-be GOD panelists, and see if we can decipher what kind of people these might be. Admitting that what follows – and, for that matter, what has just been said – amounts only to an educated guess, DrRich submits that the GOD panelists are people you already know well, if you have worked within the American healthcare system.

These are the kids you knew in college who studied all the time and got straight A’s in all the hardest courses, buttered up their teachers, then aced their MCATs. For them the hardest part about applying to medical school was in deciding which of the many schools that accepted them they should attend. Likely, they chose one of the Ivy League ones. Their first two years of medical school – the didactic years – were much like their college experiences. They studied hard, aced all the exams, and were generally acknowledged by both faculty and peers to be at the very top of their class.

Then they reached their clinical years, and things changed. They still knew more information than anyone else, and in fact their information base continued to expand. They read all the journals, and could always quote new research findings chapter and verse. They could conjugate the Krebs cycle on demand (or whatever it is you do with the Krebs cycle), and could recite precisely which enzyme that new drug inhibited, and could say why doing so made it OK to eat pizza again.

But what they could not do was be a good doctor. They had no instinct for it; no ability to get the patients to tell them the important information; no ability to read a patient’s facial expression, or phraseology, or body language, those signs that reveal the real truth. They had no ability to discern useful information from the flood of partial and contradictory clinical evidence that is always pouring in from several sources. When time was of the essence, they had no capacity to figure out what was going on or what they should do about it. They could not adjust to changing clinical situations on the fly. In an emergency they were paralyzed, trying to match the quickly evolving situation in front of them with the static words on the printed page. And often they were klutzes.

They were perfectly cut out to learn medicine, but lousy at actually doing it. What was worse, some of their colleagues who were mediocre in the book-learning department suddenly blossomed into highly competent clinicians on the wards, and quickly became recognized as rising stars by attending physicians, while they themselves were repeatedly chastised, or ignored.

And it just wasn’t right. It just wasn’t fair. They had worked harder than everyone else, had twice the brains as those others, and had learned the material three times as well. But the way God set it up, they just weren’t good doctors.

Many of these unfortunate souls quickly left clinical medicine, and branched off into research, academics, or administration. Most of them did quite well for themselves, because they really are very smart. But they never really got over their frustration and anger over their unjust  failures on the clinical wards, a place where their obvious inferiors lorded it over them. They have now spent years engaging in cognitive dissonance, convincing themselves that their apparent failure was an illusion, merely a sign of having been subjected to the anti-intellectual, shoot-from-the-hip, do-it-quickly-and-make-more-money environment that is American healthcare. After all, how could they be sub-optimal physicians when they are clearly far more intelligent and knowledgeable than the supposed “stars?” If the healthcare system had been arranged differently, in such a way as to make the cowboys behave the right way, they would have proven themselves to be the best clinicians in the land.  It is a bitter, bitter pill.

These are the guys, DrRich thinks, who are chomping at the bit for the opportunity to sit on the GOD panels. They would dearly love the chance to utilize their superior intellectual firepower, to distill the clinical research data, to digest it painstakingly and thoroughly (not haphazardly and on the fly like those others), to put down on paper the RIGHT way of practicing clinical medicine -  and to have the authority to do it in such a way (backed up by the full force of the Central Authority) that those lesser doctors will HAVE to do it their way, at long last.

The point of all this psychoanalytic guesswork is to suggest that the GOD panelists, even the GOD panelists who are physicians, will have no sympathy for the idea that the practice of medicine should be individualized to any degree whatsoever. The idea of individualizing medical care, rather than practicing by formula from a book, is what caused these people the most uncomfortable moments in their professional lives. Far from being sympathetic to the idea, they will probably be more hostile to it than the non-physicians on the GOD panels. When somebody on the panel suggests that, perhaps, we should give the doctor a little more leeway on this particular issue, these physicians will speak up and say, “Listen. I’ve been there and you haven’t. These doctors don’t need any more rope, unless it’s to bind them even tighter.” They were themselves shown no quarter, in the tough arena of clinical medicine where outcomes (and not process or book knowledge) is the only mark of success, and they will offer none in their turn.

DrRich cannot prove any of this, of course. He is just theorizing, based on his own personal observations and prejudices, having observed many of these whiz-kids in his 25 years of teaching medical trainees, and watching where they wound up. He could, of course, be wrong.

In any case, for allowing him to carry on in this manner DrRich owes one more expression of gratitude to his Progressive friends, whose doctrine of Diversity supplies the necessary substrate, and the ethical “cover,” for mercilessly stereotyping selected groups of what otherwise might turn out to be individuals.

It should by now be obvious to everyone that, in its great push to take over the American healthcare system, our government will do everything it must to eliminate private practice physicians. This is necessary because Obamacare (or any government-controlled healthcare system) simply cannot operate unless physicians cooperate completely with the Central Authority. Physician behavior absolutely must be controlled, and so doctors who insist on acting independently must either be reeducated or eliminated.

(Don’t get too exercised about DrRich’s language here – he is talking mainly about forcing recalcitrants into early retirement, or career changes. The other kind of “elimination” probably will not become necessary.)

Accordingly, under Obamacare all doctors are to be driven into federally-sanctioned organizations that will operate strictly under government directives. The current parlance for such an organization is the “Accountable Care Organization.”

The ACOs will be run by administrators who (theoretically) will become expert at navigating the morass of rules and regulations now being conjured up under Obamacare.  These administrators will interpret the rules and regulations in such a way as to determine The Way It Must Be Done, and then will pass The Way It Must Be Done down to the ACOs’ clinical chiefs (doctors who perhaps used to practice medicine, and maybe still do, a little, but who are now mainly brevet administrators), and the clinical chiefs will finally pass the restrictive rules of engagement down to the doctors who will actually take care of the patients. These doctors, struggling in the trenches, will attempt assiduously to follow those rules without exception, if they would like to keep their jobs as well as avoid a federal fraud rap. The patients, of course, will get whatever they get, but always with official assurances that whatever it is they get, it will be of the highest quality.

As DrRich has pointed out, doctors have very little leverage under this kind of system. Not only do they have the full weight of the federal government pushing them toward their fate as functionaries within ACOs, but they also are being pushed to so assimilate by their own professional organizations. Indeed, thanks to the New Age medical ethics which their professional organizations have promulgated on their behalf, joining collectives such as ACOs is about to become the only ethical way of practicing medicine. (DrRich has shown that this is explicitly so, and that Dr. Berwick agrees.) Doctors who try to make a go of it on their own will not only be practicing extra-legally, but also extra-ethically.

So this is where we are headed.

But we’re not there yet. Far too many physicians are still fundamentally independent-minded; there is still a lot of work to be done to get all the doctors to assimilate into the Borg.

And a major step in this direction will be to eliminate Independent Practice Associations. While the systematic emasculation of IPAs has been going on for years, it is to accelerate rapidly under Obamacare.

IPAs are groups of doctors who own independent medical practices, and who join together to provide bulk services to health insurers at rates of payment that are negotiated collectively. IPAs have a long and respected history for over a half-century. But they have been on the Fed’s hit list since at least the Clinton administration.

The rules under which IPAs must operate in legally negotiating with insurance companies have become complex, illogical, restrictive, arbitrary and ultimately ironic. The full weight of the federal government has been brought to bear against IPAs, apparently to protect the large and powerful health insurance companies, not to mention government health insurers, against “price fixing” by independent doctors – while simultaneously imposing price fixing by those same insurers upon the IPA physicians .

So: not only is it a violation of anti-trust for two random doctors to have a cup of coffee and mention anything to each other about their respective reimbursement rates, it is also illegal for fellow members of an IPA (who are joined together in collective bargaining with insurers) to do so. Indeed, the only kind of negotiation that is apparently allowed (“apparently” because the actual rules are not explicit but implied, and change arbitrarily depending on which administrators are running the Federal Trade Commission) is called the “messenger model” of negotiation.  The messenger model is necessitated by the fact that physician members of the IPA are not allowed to communicate with each other about rates, so each IPA must hire a “negotiator” who communicates between individual physician IPA members and the insurer. Furthermore, physicians are not allowed to declare to the insurer what level of reimbursement they will accept (because that would be price fixing), but rather, they can only hear the proposed reimbursement rates from the insurer, and accept or reject them. And in recent years, rejecting the offer by insurers, especially government insurers, has sometimes been determined also to be physician price fixing. This system, for reasons unfathomable to DrRich, is NOT to be considered price fixing on the part of the insurers.

DrRich is not sure he has this entirely right, because it is far more complex than he has allowed, and indeed, the rules are manifestly changeable and unclear, even to professional IPA negotiators.

In fact, it has proven to be very easy (and progressively easier as the years have gone by) for IPAs to get into serious trouble with the FTC, and incur massive fines, for “violations” that are not only fundamentally harmless to any party, but that had been perfectly acceptable behaviors in the recent past. To get the full flavor of the runaway prosecutorial zeal with which the FTC has been acting against IPAs, DrRich strongly recommends that you read this article in the December Reason Magazine by S. M. Oliva. (Many thanks to concerned reader Robert R. for pointing DrRich to this article.)

When the FTC decides to prosecute an IPA for price fixing or other violations-du-jour of the negotiating process, the IPA’s only reasonable course of action is to cave in immediately, sign a consent decree, pay the always-huge and always-arbitrary fine, and then abjectly accept whatever reimbursement rates the insurance company is willing to pay. This resolution to federal charges is unattractive, but at least it gives the IPA some chance of continued survival.

And if you don’t like the terms of the consent decree being imposed upon you, for God’s sake keep your mouth shut about it. When the director of a Colorado IPA recently told the press that her organization had done nothing materially wrong, but had signed the consent decree because they simply could not afford to fight the FTC in court (a truism for any IPA), the FTC sanctioned her as an individual, and barred her from negotiating with insurance companies for two years (effectively ending her career, simply for exercising her right of free speech). Even one of the FTC’s own commissioners, in a dissenting opinion, agreed that this latter action had been a travesty. (It was carried out nonetheless).

And so, operating a medical practice in an IPA has been a pretty dicey thing for several years now.

But Obamacare escalates the risk to a whole new level.

While dealing with the FTC is itself a decidedly nasty proposition, it’s nothing compared to dealing with the Justice Department. And Obamacare brings the DOJ into the fight to eliminate “price fixing” by doctors. That is, a violation of arbitrary and unpredictably changeable rules during IPA negotiations is not just a civil matter anymore, but is potentially (at the discretion of the Feds) a criminal matter.

It looks more and more like the handwriting is on the wall for IPAs, or for any independent, private practice physician who wants to take care of insured patients.

So, once again, DrRich begs his physician friends to consider the alternatives. Think about getting out now, dropping out of the system altogether while you still can, and establishing a direct-pay practice before that, too, is rendered illegal. The window of opportunity is closing.

And, sadly, you may want to re-read DrRich’s helpful suggestions regarding black market healthcare, as that may become the only viable alternative to the Borg – and much sooner than DrRich had previously thought.

In prior posts DrRich introduced his readers to Ezekiel Emanuel, MD, PhD, brother of Rahm, eminent medical ethicist, and one of the White House’s chief advisers on healthcare policy. Dr. Emanuel was one of the authors of that recent paper in the Annals of Internal Medicine which admonished American physicians that resistance is futile. He has also famously called upon American physicians to abandon the obsolete medical ethics expressed in the Hippocratic Oath.

The reason the ideas (and pronouncements) of Dr. Emanuel are important is that he presumably will be a major “decider” in determining who will serve on the GOD panels, and how those panels will operate to advance his (and Mr. Obama’s) program of healthcare reform.

So, before we leave Dr. Emanuel to his important duties, let us take one more pass at the views he has expressed, regarding the direction of American healthcare, which we can expect to see manifested in government guidelines and policies in the coming years.

In particular, and especially relevant to the subject of this blog, let us view how Dr. Emanuel would direct the rationing of our healthcare.

His ideas in this regard were probably spelled out most clearly in an article Dr. Emanuel co-authored in The Lancet, in January, 2009, which proposed a system of healthcare rationing based on what he and co-authors call the “complete lives system.” Most notably, the complete lives system proposes rationing healthcare on the basis of age, in a way that frankly “discriminates against older people” (The Lancet, Vol 373, p 429).

While Emanuel has taken a lot of heat from the right wing for espousing such a thing, his argument for doing so is unique and thoughtful, and DrRich finds it worthy of more careful consideration.

First, we should note that the outrage we often hear expressed at the very idea of healthcare rationing (with each side accusing the other of wanting to ration) only applies to politicians. When healthcare ethicists get together for instance, they (like DrRich) understand that healthcare rationing is utterly unavoidable, and that in fact we’re already not avoiding it. Ethicists argue, instead, about how to do it. In this way, DrRich feels a certain sense of brotherhood with these ethicists (a group which, in nearly every other way, DrRich most often feels a sense of disgust).

So let us consider the ethical argument most often made for discriminating against the elderly in a system of healthcare rationing. Almost always, the argument is a utilitarian one. Saving the life of a 90-year-old might “buy” him only an extra two or three years of life, whereas spending the same amount of money to save a 10-year-old might buy him another 70 – 80 years of life. So society gains much more if it spends the money on the younger person, and withholds it from the older one. From a utilitarian viewpoint the argument for discriminating against the elderly is unassailable.

Non-utilitarian ethics asserts that all individuals have equal value, so discriminating against any person should be avoided, and therefore the 10-year-old and the 90-year-old should have an equal opportunity to receive the medical service in question. (That is, either both should get it or neither should get it.)

DrRich believes that most people would sympathize with the idea that if only one life can be saved, saving a young person’s life might make more sense than saving a very old person’s life. He thinks that even most 90-year-olds he has known would agree with this proposition. The problem, DrRich believes, is with the rationale we use for making such a decision.

The utilitarian argument for discriminating against the elderly in a rationing system rests on the idea (as does all utilitarian ethical reasoning) that individuals are not of equal value, at least, not from society’s point of view. And since they are not equivalent in value, it is right and proper for some agent of society to determine the relative value of individuals, so that resources can be distributed accordingly.

Obviously, utilitarian ethics opens the door for differentiating the intrinsic values of individuals for reasons other than age. That is, if you can devalue the elderly to optimize the public good, then you can also devalue the disabled, the stupid, the lazy, the left-handed, and the obese (for instance) to optimize public good.

Emanuel’s “complete lives system,” he argues, is NOT a utilitarian one. Emanuel would favor treating the 10-year-old over the 90-year-old not to maximize public good, but to maximize the opportunity of individuals to enjoy “complete lives” over the entire age spectrum. That is, under his system all individuals are taken as having equal intrinsic value. And during the course of their lives, everyone experiences an equal spectrum of priorities – first, the priority of a 10-year-old, and later (if lucky enough to live that long) the priority of a 90-year-old. While in practical terms this still means discriminating against the elderly, it does so in a way that cannot be extended to other groups of people (i.e, the disabled and so forth), and that, in fact, yields equal age-based priorities across individuals through the course of their complete lives. In other words, when one considers the entire course of an individual’s complete life, he or she is treated the same as any other individual during the entire course of their lives.

In this way, Emanuel asserts, the complete lives system is not a utilitarian system; while it would allow us to withhold medical care from the elderly, based on their age, it would do so in a way that would not open the door for discriminating against others, for other reasons.

DrRich understands this reasoning because he proposed something entirely similar in his book, as an option for dealing with the age issue in a rationing system. In fact, since DrRich wrote his book a few years before Emanuel published his “complete lives system,” it is entirely possible that Emanuel got his idea from yours truly.

DrRich does not expect any thanks from Dr. Emanuel in this regard, however, and in fact he wishes to thank Dr. Emanuel for showing him the fatal flaw in such thinking. Indeed, thanks to Dr. Emanuel, if DrRich were to produce a new edition of his book, he would propose no such thing.

For, no sooner does Dr. Emanuel propose his complete lives system as an alternative to utilitarian ethical reasoning, than he demonstrates, in the very same article, how easily his system can be twisted to the ends of utilitarian ethics.

Specifically, Emanuel argues that a healthcare rationing system should also discriminate against the very young, and asserts that his “complete lives system” justifies such discrimination (since every individual, at one time in their lives, is very young). But in explaining why it would be desirable to withhold medical services from the very young, Emanuel reveals that his rationale, in fact, is entirely utilitarian:

“Consideration of the importance of complete lives also supports modifying the youngest-first principle by prioritizing adolescents and young adults over infants (figure). Adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants, in contrast, have not yet received these investments.” (The Lancet, vol 373, p. 428)

So, Emanuel holds that it is OK to discriminate against infants, toddlers and young children on the grounds that society has not “invested” a lot of resources in them yet. That is, their worth to society is not all that great.

This provision is extremely disturbing, to DrRich at least. For it essentially discards the notion that all human lives are of equal intrinsic value, in favor of the idea that an individual’s real value ought to be determined by their worthiness to the collective. And so society has the right and the duty to determine which individual lives are valuable enough to save, and which are not. Note that the rationale for discriminating against the elderly in the complete lives system was framed specifically to avoid having to do this.

In DrRich’s view, this provision against the young entirely negates the purported ethical premise of “complete lives.” This provision is what finally places the state, the insurers, or the GOD panels in the position of assigning intrinsic value to individual human lives, from a distance, as a matter of policy. If this can be done based on extreme youth, then it can also be done based on any other factor which some empowered panel decides will influence the worth of individuals to society.

The above figure, from Emanuel’s article on the complete lives system, reduces the question to a stark graph, with age on the X axis and value to society on the Y axis. Your age is determined by God. Your value to society is determined by the state.

It is easy to envision other, similar graphs, with your worthiness to society plotted on the Y axis, and certain personal features other than age plotted on they X axis – your income, your IQ, your disabilities, your BMI, etc.

DrRich reminds his readers that eugenics has been, from the beginning, an intrinsic part of the Progressive program. The idea that society can (and must) be perfected hinges, to a large extent, on the idea that mankind can (and must) be perfected. And perfecting mankind will require at least some culling of the herd. Indeed, early Progressives unabashedly embraced eugenics as an essential feature of societal perfection – and said so. Theodore Roosevelt, Woodrow Wilson, Bertrand Russell, H. G. Wells, and Margaret Sanger are only the most well-known of the Progressives who openly extolled eugenics.

Openly espousing eugenics became politically inadvisable after the Nazi atrocities came to light. But, since you can never achieve a perfect society while you are “carrying” a large proportion of people who are defective in their bodies, or minds, or thoughts, finding an acceptable way to eliminate such undesirables remains intrinsic to Progressivism.

DrRich believes that gaining control of the healthcare system, and gaining control of who gets what, when and how, provides both a new venue and a new language for Progressives to bring their program to fruition.

He humbly suggests that Dr. Emanuel’s “complete lives system” is an example of this new language, and that it offers a glimpse of what a system of Progressive healthcare rationing will look like.

Podcast:

In the past few posts (in particular, here and here), DrRich has shown why the health insurance industry embraced Obamacare, and indeed, took extraordinary steps to assure that Obamacare became the law of the land. This, of course, is especially interesting in light of the common perception that Obamacare constitutes a major defeat for the greedy health insurance industry. But the fact that big health insurance gave critical support to Obamacare is far more than merely interesting. It has major implications both to supporters of Obamacare, especially the ones who hope for an eventual single-payer outcome, and to opponents of Obamacare, many of whom hope to repeal it after the 2010 mid-term elections.

For the health insurance industry to have supported Obamacare, especially in the manner that it did, leads us to three conclusions.

First, while almost nobody realized it at the time, the passage of healthcare reform – in some form or another – turns out to have been inevitable. Quite simply, the insurance industry was telling us in every way they knew how that they just could not tolerate the status quo any longer. And since the insurance industry is critical to maintaining the status quo, then one way or another, the status quo had to end.

Second, the health insurance industry has just succeeded in demonstrating its great and continuing worth to the Progressive agenda, a fact that might make it more difficult than many think for Progressives to achieve their real goal – a single-payer healthcare system. If our Progressive leaders have been paying attention, the health insurance industry has taught them two important lessens in this regard.

The insurance industry has taught them that running the American healthcare system, especially under a covert rationing paradigm, is a messy, ugly and painful job, and further, that it is destined to turn out badly. This, indeed, is the chief lessen that the health insurance industry has learned over the past 15+ years. DrRich believes that many of the Progressives who are now in a position of leadership, and who are on the brink of achieving at long last a primary goal of the Progressive agenda – government control of healthcare – are aware of this fact. So they are probably not quite as self-assured about their ability to achieve healthcare nirvana, for instance, as the insurance executives were in 1994. They can see, from the experience of the insurance industry, that even draconian efforts to covertly ration healthcare are very likely to fail to slow healthcare inflation over the long term.

Furthermore, the insurance industry has taught them, if such a lesson was even necessary, just what a great boon it is to have at one’s disposal a ready villain, especially a villain which assumes the form of a business, and in particular a villain which is satisfied to play its assigned villainous role whenever called upon to do so. When things go south with Obamacare, as things will, it will go a lot easier for our Progressive leaders if they still have the insurance industry – even in a greatly diminished form – to blame. Having a foil to absorb the blame will not solve the problem, of course, but it will buy the Progressives more time, during which they can do what Progressives always do, and institute another round of “tough regulations” to hold the villains in closer check. So keeping the health insurance industry around, rather than going to a single-payer system, will indeed provide a critical level of additional insurance – albeit to our political leaders, and not to patients.

One need only look at the mortgage crisis to see another good example of the great utility of having an evil foil at one’s disposal. As readers may recall, the mortgage crisis resulted when the government instituted a free-wheeling easy-loan policy that defied every known rule of free markets, engaged Fannie and Freddie to make the easy loans, and then recruited private businesses to absorb, distribute and hide the risk. When the excrement predictably hit the fan, the investment banks (which, like the health insurance companies, did indeed behave very badly in response to fundamentally unsound governmnent policies) were offered up as the bad guys. It proved so useful to have serviceable villains during the mortgage crisis that the taxpayers were called upon to bail the villains out lest they disappear, and then, most recently, financial regulations were completely overhauled to make sure the villains will always be there. (DrRich calls this policy “Too Evil to Fail.”) In this way, Fannie and Freddie can continue making unsustainable loans, without ever having to take the blame for the consequences.

In other words, villains who reside in the domain of private enterprise are extremely useful to the Progressive program. The health insurance industry has just graphically demonstrated that it is every bit as helpful to the government’s takeover of healthcare as the investment banks were to the government’s takeover of the housing market. So DrRich, for one, bets that the health insurance industry will have a long – if unhappy – life as a government-regulated public utility, which can be called upon, whenever necessary, to display its fundamentally evil nature, in order to prove yet again that the problem is (even now!) not enough government regulation.

In contrast, once the government assumes full, direct control of healthcare (or any other aspect of the economy), then there will be nobody to blame but the government when things go wrong. (This is not strictly true. All-powerful authorities can always find somebody to blame. Historically, for instance, they often begin with the Jews, though today one must speculate that the obese will also be near the top of the list. DrRich, and, he suspects, most of his American Progressive friends, would much rather submit corporate villains to an *auto de fe* than go once again down this well-trod historical path.)

The role of Court Villain may not be exactly what the health insurance executives had in mind when they saved Obamacare, but since they had no choice in the matter, it will have to serve.

And finally, the third conclusion. Since the health insurance industry has been telling us that they are at the end of their rope, to the point that their best option was selling themselves out to President Obama and his ruthless refomers, then the idea that Obamacare can simply be repealed, or de-funded, or de-featured, or declared unconstitutional, so that we can just go back to the healthcare system we’ve had since 1994, is absurd.

Indeed, even though Obamacare is now law, the health insurance companies are by no means out of the woods. There remains a real question as to whether the provisions of Obamacare will be sufficient for the short-term viability of the health insurance industry.  Most of the provisions of Obamacare – in particular, the individual mandates the insurance companies are relying upon for their One Last Windfall – do not go into effect until 2014.

At least until then, the insurance companies likely will need to keep increasing their annual premiums at astronomical rates in the attempt to remain sufficiently profitable. Can the system sustain such increases until 2014?  Or, will the provisions of Obamacare have to be accelerated? Or, will Obamacare have to be revised, for instance, to add the much reviled (or much desired, depending on your political views) “public option?”

But while Obamacare may need to be accelerated or further radicalized, it cannot just be repealed. For the same reason that healthcare reform was inevitable, we can’t just go back. The insurance industry simply will not tolerate it.

What we all have to remember – and the main point of this series of posts – is that we can’t just get rid of Obamacare and go back to the way things were.  If we think we need to substantially change Obamacare, so as to shed ourselves of the extremely disturbing spectre of government-controlled covert rationing (which will be far more destructive than the insurance-company-controlled covert rationing we’ve painfully endured for 15 years), we’ll need to have another solution in hand.

DrRich, of course, knows such a solution, and he has described it in detail elsewhere.

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Why Big Health Insurance Supported Obamacare

Part I – Another Reason He Should Have Kept the Bust

Part II – Why the Health Insurance Industry Supported Obamacare

Part III – How the Health Insurance Industry Saved Obamacare
________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Now on Kindle!

Podcast:

As we have seen, the fact that the health insurance industry was going to support healthcare reform after the 2008 elections was a foregone conclusion.  The question was: How would the insurance industry support healthcare reform?

When the time came, the support the insurance industry gave to President Obama’s efforts to reform healthcare followed four simple rules:

1) Do not actively oppose Obamacare. In stark contrast to its behavior during the Clinton’s effort to reform healthcare in 1993-94, this time the insurance industry never engaged its vast public relations resources to stifle healthcare reform.  There was no Harry and Louise this time. (Actually, Harry and Louise – the original actors – did make a brief appearance, but now, like the insurance industry itself, they were older, wiser, and sadder, and this time they fully supported the proposed reforms.)

2) Submit quietly to demonization.  A key strategy of the Democrats in passing Obamacare was to remind Americans repeatedly that the for-profit health insurance industry is fundamentally evil.  This strategy was based on the time-honored precept that it is easier to get the unwashed masses to cooperate through hatred than through reason, and so, to gain their cooperation, one must give them something to hate. Obviously, this strategy meant that the health insurance industry had to accept its role as the bad guys in the reform debates without complaint, and without engaging in any serious self-defense.

3) Offer subdued public support to Obamacare. The AHIP (America’s Health Insurance Plans) issued public statements that cautiously supported President Obama’s healthcare reforms. But its support had to remain subdued and tepid, since Satan can’t be seen leading the hymns.

4) Whenever necessary, rise up and demonstrate to the world just how evil you really are. At the end of the day, this was the most important role the insurance industry played in advancing Obamacare. It was certainly their most active role.

It was not a difficult role to fill. Since 1994 the health insurers had engaged in the sorts of truly evil, inhumane, and reprehensible practices that are naturally engendered by covert healthcare rationing, and that harmed or killed many of their subscribers. The only difficult part was choosing which reprehensible behaviors to feature, and when to do it.

In at least two key moments during the fight over healthcare reform – June, 2009 and February, 2010 – when the proponents of reform felt their momentum lagging, the insurance industry intervened with gratuitous behaviors whose chief function was to remind Americans just how unremittingly wicked and inhumane they really are. In the second case, at least arguably, the insurance industry turned the reform effort from apparent defeat to almost certain victory. Indeed, it is not too much of an exaggeration to assert that, in the end, the health insurance industry saved Obamacare.

June, 2009: Say Hello To My Little Friend

The debate over Obamacare entered a new phase in May and June of 2009.  It was during those months that the opposition to healthcare reform found its voice, and it began to seem as if perhaps the Obama steamroller could really be slowed, if not stopped. People were even beginning to say that many Democrats in Congress, after getting an earful from their constituents when they held their summer town hall meetings, would abandon any idea of supporting President Obama’s healthcare reforms.

Supporters of Obamacare decided it was time to invoke the demons.  So in mid-June, the House Subcommittee on Oversight and Investigations called three health insurers to testify on the practice of rescission, and to face not only indignant Congresspersons, but also some of the people who had been personally harmed by their practices.

“Rescission” is when an insurance company voids subscriber’s health insurance (after happily accepting premiums from that subscriber, often for many years) once they get sick. Under some circumstances, rescission might be justifiable. It is legal and proper to cancel a policy if the subscriber is found to have purposely lied on the insurance application about a prior illness that is material to the current illness.

But health insurance companies for years have actively and aggressively practiced rescission on subscribers whose insurance applications contained inadvertent and non-material inaccuracies.  (Just to put it in perspective, this kind of bad behavior is to be expected under a system of covert healthcare rationing, which again, is rationing by whatever means you can get away with.)

Furthermore, the health insurance industry does not merely engage in occasional unfair rescission practices; it has industrialized the process. It employs health insurance detectives whose job is to comb the prior medical records of subscribers who are newly diagnosed with certain, expensive medical conditions, looking for even trivial discrepancies on insurance applications, which they can inflate to “fraudulent” omissions, thus voiding the policy. These health insurance detectives are paid by commission, according to how much money their efforts can save the company. Many of them find it a very lucrative career.

So, at the cost of perpetrating a bit of inhumanity, rescission can save insurance companies a lot of money.

Consider some of the individuals who testified in Congress along with the insurance companies that day

• A nurse in Texas had her insurance canceled after she was diagnosed with breast cancer because she had failed to reveal that, years before, she had consulted a dermatologist about acne.
• A man (whose surviving sister had to testify) had his insurance canceled before he could begin expensive cancer therapy, because he had not revealed (and indeed he had not known) that a prior CT scan had showed gallstones and an aneurysm – conditions unrelated to his cancer.
• A woman had her insurance canceled – and due to the rescission could not find replacement insurance – because she failed to reveal that, at one time, she had been on medication for irregular menstruation.

During the hearing, the three health insurance executives were caused to listen to these and other incredible stories describing some of the inexcusable pain, suffering and death their unfair rescission practices had caused, and then were forced to listen to withering commentary by stunned Republicans and Democrats on the Subcommittee, whose own investigation had found that the three companies on the docket had retrospectively canceled the policies of 20,000 sick subscribers over the past 5 years.

After these heart-rending testimonies and the blistering attacks from extremely angry congresspersons, the executives were challenged by Chairman Stupak (D-Michigan) to now commit to discontinuing the practice of rescission unless intentional fraud could be shown.

All three replied, in turn, “No.”

Such a reply, in such a setting, almost defies belief. The only possible explanation, in fact, is that the insurance industry was stepping up to the plate, and embracing its assigned role as the Evil One in the great healthcare debate.

Even the most stone-hearted insurance executive can see that canceling the health insurance of a newly-diagnosed cancer patient, because she’d forgotten she’d required acne medicine before the prom 20 years ago, is just a bit unfair. But how did these three executives react? They did not attempt to deny such reprehensible behavior, or to explain it, or to defend it.  They were simply defiant about it.

One is put in mind of Tony “Scarface” Montana, bereft of friends, family, allies and bodyguards (albeit because of his own actions), hopelessly surrounded by an army of heavily-armed assassins, screaming, “Say hello to my little friend!” then launching defiantly into a wild, bloody and spectacular suicide.

One cannot for a moment believe that that Richard A. Collins, chief executive of UnitedHealth’s Golden Rule Insurance Co., Don Hamm, chief executive of Assurant Health, and Brian Sassi, president of consumer business for WellPoint Inc., would have been stupid enough to publicly defy Congress over such an indefensible practice, if doing so was against their own long-term interests.  Appearances to the contrary notwithstanding, they were not auditioning for a remake of Scarface.

This is not how an industry behaves which wants to court the goodwill of Congress at a critical juncture in its life cycle. This is not the strategy of an industry that wants Congress to defy its own party’s President and defeat healthcare reform, or that is begging Congress to give them another chance to figure out how to bring healthcare costs into check. This is not the behavior of any industry that wants to elicit any sort of favorable action from Congress. Indeed, these executives would have seemed more sympathetic and deserving if they had proposed instead to place live puppies on a spit and roast them over an open fire during half-time at the Super Bowl.

There is only one explanation for their astounding public defiance on this matter. Which is, it must have suited their long-term interests.

Recall that at the time of this remarkable hearing, there was growing skepticism about President Obama’s healthcare reform efforts, not only on the part of Republicans, but also on the part of a critical minority of Democrats in Congress. And for the first time since the election, there was some question about whether his reform plan would succeed in gaining sufficient support.

What must the health insurance industry do in the face of this faltering support for its desperate end-game? It must act to bolster Obamacare.

In this light the stark, defiant, public “no” uttered by the three insurance executives makes sense. “Look at us,” they were saying, “See how evil we are! We are utterly devoid of human decency, ethical obligations, or a sense of fair play. If we behave this defiantly when we are in the position of mere supplicants to your eminences, just think how we will behave if you fail to rein us in with new reforms!  Abandon all hope, those of you who rely on us for your healthcare, and behold the congressional dogs that placed us in this position of power over your very lives!”

Given the headwinds the healthcare reform effort was to face during the next nine months, it is difficult to say with any certainty how much good the insurance industry did in June, 2009, when it took such an extraordinary step to remind Americans just how incredibly evil it is. But when the time came to help boost the President’s reform efforts, nobody can deny that the insurance industry stepped up and did its duty.

February, 2010: Raising Obamacare From The Dead

Things looked especially bleak for healthcare reform in early February of 2010.  The incredible, possibly Constitution-defying, machinations Congress employed in its desperate attempt to pass healthcare reform had disgusted a majority of Americans, and momentum was clearly shifting to the opponents of Obamacare. And when Republican Scott Brown incredibly won the Senate seat in Massachusetts, robbing the Democrats of their crucial, filibuster-blocking 60th vote, many thought healthcare reform was dead.

But then out of nowhere, in early February, Wellpoint’s California subsidiary, Anthem Blue Cross, announced it was raising its already-astronomical health insurance premiums by as much as 39%, a move that promised to greatly increase the number of Californians who are uninsured.

The demoralized Democrats in the administration greedily capitalized on this new opportunity.

Kathleen Sebelius immediately fired off a very public letter to the company, demanding that they justify this unconscionable rate increase. And Wellpoint, lustily assuming its assigned role as villain, was delighted to reply, equally publicly.

We’re in a recession, Wellpoint brazenly asserted, and in a recession, like it or not, people exercise their prerogative to drop their health insurance. The only people who don’t drop their health insurance are the sick people, or those who are likely to become sick, which means that our cost per subscriber goes way up. So naturally, we have to increase premiums. By a lot. It’s just business. That’s just the nature of our current, unreformed healthcare system. So choke on it.

Wellpoint was also kind enough to mention (for anyone dense enough to have missed the point) that the need for higher insurance premiums would be nicely mitigated if everybody was mandated by the government to purchase health insurance.

Wellpoint’s anounced premium increase immediately triggered great volumes of delighted outrage by thankful Democrats, who desperately needed a large dose of “evil insurance company” at just that time. Wellpoint’s action reignited the proponents of healthcare reform, who were inspired to remind all Americans that this is what would happen to everyone if healthcare reform failed, and the greedy insurance companies had their way.

Stunned Republicans, seeing their impending victory over Obamacare evaporating before their eyes, could only issue a few lame and uncomfortable attempts to diminish the significance of Wellpoint’s unfortunate action.  But to little avail. The momentum had shifted. At least arguably, it was Wellpoint’s decision to announce an unconscionable rate increase at this extremely critical juncture that put healthcare reform back on the road to adoption.

From a pure business standpoint, there was no good reason for Wellpoint to stir the soup at that moment. Wellpoint is the most financially sound private health insurance company. While its California subsidiary did lose money in 2009, overall the company performed quite well, and reported a very nice profit growth for the year. And with several of its competitors in trouble, Wellpoint stood to do comparatively well for the foreseeable future.

Furthermore, it has since been learned that Wellpoint’s math was bad. An independent actuary working for the California Department of Insurance reported on May 5, 2010 that the company had made “numerous errors” in calculating is rate increases, and further, that Wellpoint could cut its rate hikes substantially, and still meet its required 70% medical-loss ratio threshold.

It stands to reason that if Wellpoint really wanted healthcare reform to go away, they would have first checked their math before announcing seismic rate increases, and then, if such astounding rate increases were really needed, they would have waited a few months – while Obamacare died – before announcing their rate hike.

The last thing they would have done is to throw the reformers a critical lifeline just as they were going under for the last time.

In any case Wellpoint’s action, especially at that moment, seems entirely gratuitous. Wellpoint could only have chosen to do its demon dance, at such an inopportune moment, in order to revive Obamacare during its darkest hour.

And that’s precisely what happened.

In the final post in this series of articles, we will take a look at the implications of the insurance industry’s support of Obamacare, as we who find Obamacare less than desirable contemplate what we ought to do about it.
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Why Big Health Insurance Supported Obamacare

Part I – Another Reason He Should Have Kept the Bust

Part II – Why the Health Insurance Industry Supported Obamacare

Part IV – What It Means That the Health Insurance Industry Saved Obamacare
________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Now on Kindle!

Podcast:

The fact that the health insurance industry supported Obamacare from the very beginning was entirely missed by the mainstream press. This is perhaps understandable, since a) the mainstream press does not understand the dynamics of the healthcare system, and b) during the Obamacare drama, the health insurance companies had been assigned, and had graciously accepted, their vital role as the Forces of Evil. To the famously credulous members of the mainstream press, it was easy to imagine that the insurers were actually among the opposition.

But the insurance industry supported Obamacare from the start – and even before the start. During the Presidential race of 2008, for instance, managed care companies donated far more money to both Barack Obama and Hillary Clinton than to any Republican candidate, even though both of these Democratic candidates publicly castigated the insurance companies for producing most of the problems in American healthcare, and promised to institute reforms that would drastically cramp their style and reduce their profits.

Why would the insurance industry support the very candidates whose chief healthcare strategy was to demonize them? Quite simply, it was because the insurance industry had nowhere else to go.

By the time Mr. Obama became president, the once proud, self-confident, and even arrogant American health insurance industry had been completely humbled. Like the old Soviet Union twenty years earlier, it still may have looked formidable from the outside, but it was really an empty shell.  The industry had run out its string; it was entirely bereft of ideas. Its business model was completely broken, and it desperately needed an exit strategy. And it was due to the need to find a serviceable exit strategy that the industry supported Obamacare.

To understand what landed the insurance industry in this sad state of affairs, it is necessary to review its recent history.

The Rise of the For-Profit HMOs

When the Clintons set out to reform the American healthcare system in 1993, the health insurance industry initially claimed to support them. The Clintons had promised them a vast new market – the millions of heretofore uninsured Americans whose premiums would be paid, presumably, by the government.

But the alliance fell apart the moment the insurance industry began reading the massive tome of regulations the Clintons finally produced, and found in it much they didn’t like. Chiefly, they they didn’t like the parts that ceded full control of their industry to the government. So Big Health Insurance immediately turned against the Clintons, and spent millions of dollars introducing us to Harry and Louise (a “typical” American husband and wife who were viewed in numerous TV commercials discovering various appalling provisions of the Clinton plan). In the end, when the Clinton’s reform plan went down to ignominious defeat, the powerful health insurance industry, appropriately, got most of the credit.

Most of us Americans were happy at the time that the Clintons’ plan had been defeated, but during the debate over healthcare reform we had become convinced that the old way of doing healthcare wasn’t any good either. The healthcare system, we all knew by now, was bankrupting us.  And something needed to be done about it. But with the Clinton plan off the table, what were our options?

In the ashes of the Clintons’ failed effort, the health insurers saw their golden opportunity.  And they presented the American people with a savior. The savior was, of course, them.

The insurance industry made its pitch in a new guise which we Americans had never seen before. For the big fee-for-service insurance companies had transformed themselves into HMOs, and had fully assimilated the language of managed care. These were not the touchy-feely, non-profit HMOs that had been puttering around in the healthcare system for a decade or so.  These were meat-and-potatoes, for-profit HMOs, run for the most part by hard-nosed business executives, and newly formulated for a new era of American healthcare.

And here is what they said: “Citizens! We all – employers, patients, physicians, hospitals, manufacturers and insurers – have just dodged a bullet. Thanks to us, the frightening socialist reforms of the Clintons have been soundly defeated. But where does this leave us? We stand now between Scylla and Charybdis, between the specter of nationalized healthcare on one hand, and the continued profligacy of traditional fee-for-service medicine on the other. And we cannot countenance either. But here,” they continued, “is a third way. A painless way, based on the sound principles of managed care, open markets, and free enterprise. Let healthcare become a business like any other business, and the market forces will find ways not only to cut costs but also to improve quality, and with no government intervention.”

The offer, in other words, was to turn healthcare over to the business professionals now running the New Model HMOs, who were cocky with the certainty that they could harness the efficiencies of the marketplace to control costs, make a big profit at the same time, and be feted as saviors to boot. Because we’re Americans and we know the benefits of capitalism, and because the other choices we faced looked even worse, we all said, “Go for it.”

This change led to the most rapid transformation the American healthcare system has ever seen, and within a few short years, the majority of Americans were enrolled in HMOs, or some other species of corporate managed care.

So HMO executives set out to control the cost of American healthcare, and to make a spectacular profit doing it. And for a few years, they seemed successful. Healthcare inflation slowed dramatically in the late 1990s, and HMO profits soared.

But it was all an illusion.

The Fall of the For-Profit HMOs

The initial impressive profitability of New Model HMOs was due to the one-time reduction in cost you always get when you implement efficiencies of scale (made possible by merging enterprises), and by instituting the new standardization techniques favored by managed care theory. These steps reduced the cost of healthcare for a while, but the underlying rate of healthcare inflation (which is mostly caused by new medical technologies and an aging population, neither of which are cured by managed care) was pretty much unchanged. So by the early 2000s, when these one-time cost reductions had been fully realized, healthcare inflation was right back on the same unsustainable trajectory it had been on before.

Unfortunately for the HMOs, the big profits they enjoyed throughout the 1990s could not last. Their rapidly expanding valuations were attributable not to their efficient management of healthcare, but instead, to the frenzy of mergers that rapidly ensued, and to the acquisition and privatization of not-for-profit public assets for a tiny fraction of their true value.

So not long after the turn of the century the for-profit managed care companies were getting very nervous. For the very first time in their history, HMOs were faced with the prospect of having to earn their profits, profits sufficient to satisfy their shareholders, by actually managing the healthcare of sick people. This is something they had never accomplished before, and, by the time the election of 2008 approached, they knew they never would.

By that time they had tried everything. Beginning in 1994, filled with confidence and enthusiasm and cheered on (initially, at least) by the public and by public officials alike, the health insurance companies had more than 15 years of more-or-less unfettered freedom to institute any efficiencies they wanted to. In the ensuing years insurance companies tried all kinds of legitimate ideas for reducing healthcare costs, such as managed care, gatekeepers, clinical pathways, disease management programs, pay for performance, wellness programs, medical homes, and even a ruthless consolidation of the industry to achieve “efficiencies of scale.”

They also tried every sneaky and underhanded idea they could think of for reducing costs, like cherry-picking the healthy patients, treating chronically ill patients like pariahs so they would go away, making access to specialty care as inconvenient as possible, forcing doctors to sign “gag clauses” to prevent them from telling their patients about certain treatment options, browbeating primary care physicians into zombie-like compliance with handed-down care directives, refusing to cover expensive-but-effective medical services, and canceling the policies of tens of thousands of patients after they get sick, based on trumped-up technicalities. Indeed, they tried everything short of dispatching teams of Ninjas in the dark of night to slaughter their most expensive subscribers in their beds.  And finally, when all else failed, they instituted huge and unsustainable annual increases in premiums, to the point of driving their customers out of the market. (This latter move, of course, was an open acknowledgment that the industry had entered its death spiral.)

All these efforts were to little avail. The cost of healthcare continued to skyrocket, entirely unabated. And by 2009, when President Obama began his push for healthcare reform, the insurance companies knew they had no prospect of long-term profitability. Their business model was no longer viable, and, while telling soothing stories to avoid shareholder panic, they were urgently casting about for an exit strategy.

A drowning man will cling to any piece of flotsam that comes his way.  What the insurance industry found floating by was Obamacare.

What Health Insurers  Get From Obamacare

In return for its support in the healthcare reform battle, President Obama offered the insurance industry the graceful exit strategy it so desperately needed.  Under Obamacare, for at least a few years the insurers hope to get One Last Windfall – namely, profits from the influx of previously-uninsured Americans whose premiums will be paid, or at least subsidized, by taxpayers.  Here, the insurers are relying on the likelihood that the inflow of new premiums will, for a year or two at least, greatly outweigh the outflow of money they will have to spend caring for these new subscribers. Obviously, they will use every trick in their well-worn book to stave off expenditures for these new subscribers for as long as they can, but if they actually knew how to avoid paying healthcare costs indefinitely, they wouldn’t be seeking a government bail-out today. In any case, an inflow of new subscribers will be a very temporary source of profit for insurers. Hence, at best it is One Last Windfall.

What happens to the insurers after they exhaust this last windfall is still up in the air. Obamacare may, of course, eventually transition to a single-payer system, an outcome which many conservatives desperately fear, and many liberals fervently desire. In this case, there may very well be some final compensatory buy-out (or a buy-off) for the insurance companies. But more likely, the insurance companies under Obamacare will continue to exist essentially as public utilities. That is, they will exist as companies chartered by the government, which administer healthcare under the direction of the government, with the products they may offer, the prices they may charge, the profits they may keep, and the losses they may incur, determined solely by the government.  It’s not glorious, but it’s a living.

And it’s much better than where they would have ended up without Obamacare. Which is why they supported it from the start.

Now that we know why the insurance industry supported Obamacare, in the next post we will explore how the industry, at no small cost to its own public image, supported the President when it counted most.

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Why Big Health Insurance Supported Obamacare

Part I – Another Reason He Should Have Kept the Bust

Part III – How the Health Insurance Industry Saved Obamacare

Part IV – What It Means That the Health Insurance Industry Saved Obamacare

________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Now on Kindle!

Podcast:

When President Obama moved into the White House in January of 2009, he found in the Oval Office a bust of Sir Winston Churchill, a gift from Great Britain to the United States during the Reagan presidency, a gift meant to symbolize the close ties between our two nations. The new President quickly decided he did not want to look at it. And, as one of the first acts of his presidency (before advancing his Stimulus Package, or pushing healthcare reform, or even inviting Andy Stern to dinner), he had that bust placed into a crate, packed with sawdust, and shipped by the afternoon mail right back to England.

DrRich can think of several reasons why it might have been a better idea, instead of beginning his reign with a completely gratuitous insult to America’s longest and best and most-needed ally, for President Obama to quietly have had the bust moved to the White House basement, where Sir Winston could have spent the next four to eight years contemplating all those other now-obsolete or embarrassing diplomatic trinkets, such as the gold plate from the Shah of Iran, and the fine old portrait of Ferdinand and Imelda Marcos.

And here’s one of them.

Despite the fact that President Obama was elected by a wide margin, and that he brought with him a filibuster-proof majority in the Senate and a large majority in the House, and that he had loyal, powerful and dogged leaders in each chamber of Congress who completely supported his agenda, and that the major American media was largely behind him all the way, the passage of the Obamacare legislation was very hard-fought, and a very close thing. Its ultimate passage was a major victory for the President, and a great tribute to his persistence. In fact, DrRich believes that President Obama has not received nearly enough credit for the utter doggedness and persistence he displayed in the face of the terrible headwinds he sometimes encountered while passing his healthcare reform agenda.

Indeed, during this arduous process, he was almost Churchillian in his steadfastness.

So, had he kept it, President Obama might now gaze upon bust of Churchill and see not the man who had campaigned against people of color in order to keep the British Empire together, but rather, a man who, not unlike himself, had almost single-handedly saved western civilization from the forces of evil.

But there is another striking similarity between these two men, aside from the remarkable singlemindedness they displayed under pressure, which is: neither of them could have succeeded alone. Their iron will, their persistence, their personal courage, and their (too often weak-kneed) support from political allies would not have carried the day, had it not been for the assistance of a powerful, if silent, partner.

In 1940-41, when Winston Churchill stood virtually alone against the Nazi onslaught, and with dwindling resources and a badly beaten military tried to face down a powerful enemy, he utterly relied on the support – often tacit, rarely public, only occasionally material, but always firm and unwavering – of Franklin Roosevelt. And no matter how bleak things looked, Churchill always believed that, one way or another, in the end President Roosevelt and the great might of the United States would provide a way to final victory.

Similarly, when the President’s initially smooth path to healthcare reform was suddenly interrupted by a blitzkrieg of contentious town hall meetings, followed closely by the formation of the vociferously anti-Obamacare Tea Party movement, followed next by the surprising victory of Chris Christie for the governorship of New Jersey, and capped by the stunning ascension of Scott Brown to the Senate seat long held by Ted Kennedy, an event that appeared to leave the prospects for healthcare reform so bleak that a week later the issue was barely raised in the State of the Union address, and that caused even the sympathetic press and some of his fellow Democrats to declare the prospects for healthcare reform to be dead, President Obama had to reach deep within himself to find the resolve for one last push. And in that dark moment he, too, was able to draw courage from the tacit, rarely public, only occasionally material, but strong and unwavering support of his own silent partner.

That silent partner, of course, was the American health insurance industry.

And as was the case with Sir Winston, in the moment of greatest crisis President Obama’s own silent partner threw itself into the fight with great abandon, and ultimately enabled a final victory.

Why the health insurance industry supported Obamacare, and how it did so, should be of more than mere casual interest to Americans. It has major implications for anyone who favors repealing Obamacare or major parts of it, or de-funding it, or declaring it unconstitutional. Anyone who is approaching the 2010 mid-term elections thinking that we can just get rid of Obamacare and go back to the way things were – or even to a substantial modification of the way things were – had better understand what just happened.

So in his next few posts, DrRich will examine the role that the American health insurance industry played in the passage of Obamacare, and what the recent behavior of that industry implies as we decide what we should – and can – do next.

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Why Big Health Insurance Supported Obamacare

Part II – Why the Health Insurance Industry Supported Obamacare

Part III – How the Health Insurance Industry Saved Obamacare

Part IV – What It Means That the Health Insurance Industry Saved Obamacare

________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Now on Kindle!

When DrRich was a little tyke, he always loved it when Uncle Harry came to visit. Uncle Harry was a large, rotund man with a ready smile and a jolly laugh, who was genuinely delighted to spend hours entertaining little DrRich and all the other children with his jokes, stories, magic tricks, and samples from the large stash of candies he always kept in his coat pockets. We all loved Uncle Harry.

But we were deceived.

Little did DrRich know, in his youthful innocence, that far from being the cheerful and beloved amateur prestidigitator delighting us with his his egg trick, Uncle Harry was actually a menace. For Uncle Harry was obese.

We now know, of course, that obese people, through their gluttony, sloth and lack of self-control, are causing untold harm to our society. They are unpleasant to sit next to on buses and airplanes. They use more than their rightful share of healthcare resources. They snore. They cause excessive tire wear (and if they sit in the same seat all the time, the tire wear will be asymmetrical, probably leading to an increase in automobile accidents).

And now, thanks to a recently published academic article, we know that the obese are largely responsible for global warming.

That global warming is taking place, and that it is being produced by mankind, of course, is a settled issue. DrRich is led to understand that a great council of hand-picked environmental scientists, taking a lesson from the Council of Nicaea, has met and has decreed it to be so. The entire body of scientific evidence has been formally considered, and like the Holy Scripture has been carefully locked down into its final form, and has been divided into orthodoxy (the study of which is holy) and heresy (the study of which leads to perdition). And having accomplished this task, the scientific community will hereafter countenance no dissension on the matter, and will admit no further debate or even any further data (unless it is corroborative data). For this is how science is supposed to work, at least for matters as critically important as global warming.

DrRich calls it Environmental Scholasticism, and believes it is about time we returned to a system of thought that was good enough for some pretty important Saints. The notion that scientific viewpoints should never be considered “closed,” and should always be open to challenge as new evidence and new ideas come to light, is a relatively recent invention initiated by the likes of Galileo and Newton, and has led to nothing but trouble (such as, for instance, global warming).

In any case, now that we know once and for all that global warming is man-made, it behooves us to figure out which men (and women) are causing it. And now, according to two eminent scholars at the Department of Epidemiology and Population Health, at the London School of Hygiene & Tropical Medicine, we know that among the chief culprits are the fat. That is, fat people, through the office of their obesity itself, are responsible for a significant degree of the carbon emissions that are unarguably (and officially) destroying our planet.

This fact, heralded by radio and newspaper reports proclaiming, “Fatties Cause Global Warming,” was revealed in a “scientific” paper written by Professors Edwards and Roberts and published by the prestigious Oxford Press in the International Journal of Epidemiology.

The paper really ought to be perused directly to appreciate the elevated level of scholasticism employed by the authors, which would make even Thomas Aquinas and Albertus Magnus themselves sit up and take notice. For this paper, which indicts a whole class of individuals with the supreme crime of global warming, a crime whose disastrous effect on our planet eventually will make the atrocities perpetrated by even Hitler and Stalin seem mere trifles in comparison, reaches its conclusions without ever offering even one tiny glimmer of actual data or evidence.

Rather, the authors rely (as true scholastics must) on the approved body of scientific work, choosing from that body an array of assumptions based on bits of sanctified data from physiology here (e.g., Basal Metabolic Rate = 11.5 X body weight in KG + 873kcal), and behavioral science there (e.g., that the average daily activities of humans consists of 7 hours sleeping, 7 hours of office work, 4 hours of light home activities, 4 hours sitting, 1 hour standing, 30 min of driving and 30 min of walking at 5 km/h), then applying these bits to an incredible chain of assumptions and estimations, to demonstrate that the negative impact of the obese on our society goes far beyond what we currently think. Indeed, through such machinations it can be concluded that the obese are melting the ice caps, killing polar bears, flooding the seacoasts, and turning our farmland, forests and fields into hot, dry, desert.

Anyone with a cheap telescope can conclude from all this that Martians, when they existed, must have been really fat.

This information, of course, will come in very handy when we are forced at last to reduce our healthcare costs, and we find we need somebody to blame. We can already discriminate against smokers with a clear conscience. And now discriminating against the obese can be accomplished not only with a clear conscience, but with a sense of duty. For, far from merely costing the healthcare system a lot of money, they are killing us all and ruining our planet.

Indeed, DrRich himself was sharpening his pitchfork, when a thought occurred to him.

The paper in the International Journal of Epidemiology comports to the classical scholastic practice of “lectio,” whereby a learned person expounds on a certain interpretation of the approved texts, and allows no dissension or questioning. But scholasticism also offers a process for “disputatio,” whereby alternative interpretations of the approved texts are permitted to be offered, and the two viewpoints are then subjected to logical analysis through which the truth is determined. (Though in classical scholasticism, the “truth” is ultimately determined by the scholar who delivered the original lectio, and the disputant is put in his/her place.*)

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*This, of course is where Martin Luther went wrong. The 95 Theses he nailed to the church door at Wittenberg was essentially an offer to engage in a classical scholastic “disputatio.” He was merely inviting a debate, like any other scholastic debate, and nothing more. The clergy, however, proved a bit too easily offended, and Luther proved a bit too tetchy, and the intended academic exercise turned into 300-years of bloodshed. DrRich sincerely hopes to avoid such a result here.

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So in the spirit of Environmental Scholasticism (but for the ultimate purpose of discovering whether the healthcare system ought to cure, ignore or euthanize the obese), DrRich would like to propose an alternative interpretation of the argument that the obese are causing global warming. That is, he will offer a disputation.

The logic of the two eminent scholars Edwards and Roberts, once you wade through the incredible morass of scientific-sounding language they have produced, essentially rests on two arguments. First, that the obese require more food energy for their basal metabolic requirements, and second, that because they are so fat they travel in cars (and very big cars at that) much more than normal people do. For these two reasons the obese produce way more carbon emissions than they are supposed to. The authors go on to calculate the excess carbon emissions produced by the obese via the aforesaid impressive chain of assumptions and estimations, and the magnitude of that excess shows us plainly that the fat are largely to blame for global warming.

This is when it occurred to DrRich that both of the basic arguments of Professors Edwards and Roberts can be easily countered, well within the bounds of the scholastic arts, using only the approved texts and without introducing any new (which is to say, heretical) data.

So, to their lectio, DrRich advances this disputation:

First, DrRich asserts that while the basal metabolic rates of the fat are indeed higher than those of the thin, one reason the thin are thin is that their non-basal metabolism is high. That is, often they habitually engage in exercise, even running marathons and triathalons, which burns many calories and produces much CO2. Scientific studies have shown that the obese tend to be still, serene, relatively inanimate. On the other hand thin people are fidgety, they pace about, wave their hands, bounce their legs, and excrete much CO2 through largely habitual and non-useful activity. Perhaps we should punish the calorie-burning thin rather than the fat. At least when the obese burn calories they are generally doing something useful.

Second, while thin people do ambulate more than the obese (indeed, this is DrRich’s first point), the assumption that the obese must make up that mileage by driving cars is entirely ridiculous. The thin actually drive far more than the obese, because they have places to go and things to do, and they’re in a hurry to get there and do it. In contrast the obese are efficient in their movements, they preserve their energy. Thus, they do not drive to the grocery for a pint of milk on a whim. They plan their trips carefully, and shop for the entire week with one trip. There is no evidence that the obese require more support from internal combustion engines than do the thin, and simple observation in fact suggests the opposite.

DrRich could, with some effort, produce a paper just as scientific-sounding as that of the Professors to “prove” his points, but will not do so here. Instead, he will just state his points as bald assertions – which (despite all the fancy math they attached to it) is just what his opponents have done.

DrRich maintains that his two assertions – which entirely counterbalance those of his opponents – make his argument equally compelling to theirs. So thus far we have a draw. But DrRich’s third assertion, which follows, wins the day.

To wit: The obese are unarguably sequestering carbon.

Storing fat, in fact, is simply a relatively efficient way to store carbon. The obese consume massive amounts of carbon in the form of food, and then they fail to burn it off (unlike thin people, who convert their food to CO2 immediately through their habitually wasteful activities). Instead, the obese store their carbon intake in massive reservoirs of fatty tissue, taking it out of circulation forever, and removing it from the carbon cycle which (we find) is so fatally damaging to the earth. Indeed (at least according to the zero-sum crowd for whom redistribution is invariably the answer to all problems), the more food consumed by the obese, the less food remains available for the thin people who would just go ahead and metabolize it, with all their jogging and whatnot, excreting lots of excess CO2 in the process.

When we finally institute our cap-and-trade economy, the obese should get a tax break based on their weight.

Carbon sequestration, of course, is one of the holy grails for environmentalists. Lots of methods for sequestration have been proposed, but none seem particularly practical. One method that has been considered is called “Biomass Burial,” in which we would take some form of biomass (plants have been the main source proposed) and bury it under the earth. The carbon from the buried biomass will stay in the ground, and will not contribute to global warming, at least not for a long time. (This is how fossil fuels are said to form in the first place.)

As long as we insist that fat people are buried (preferably after they die), and make cremation of the obese illegal, then putting the obese into the ground will constitute the much-sought biomass burial. When we bury deceased fat people, it is plain to see that we are removing tons and tons of carbon from the carbon cycle and thus from the atmosphere, and instead sequestering it in the ground. It brings a tear to DrRich’s eye to imagine that his king-sized Uncle Harry, gone now for the better part of three decades, by virtue of all that carbon he took with him under the earth continues to make the world a better place for all us former kids he used to delight with his card tricks and his stupid jokes.

And finally, this happy conclusion at which we have arrived – that the obese actually reduce global warming – at last informs those of us who are interested in healthcare how we ought to behave toward the obese. As long as fat people are maintaining (or better yet adding to) their weight – that is, as long as they continue to remove large amounts of carbon from circulation – we should encourage their continued good health. If, however, they start exercising or in some other fashion begin to burn off their large carbon deposits, then of course we might logically withhold medical care from them, or even encourage euthanasia.

But please, for the love of our precious planet and for the sake of our polar bear citizens, let us not discriminate against the obese, or discourage them from their important work.

________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Now on Kindle!

DrRich is relieved to learn that the world’s most famous global warming experts have now been exonerated by three separate formal reviews. Dr. Michael Mann from Penn State University was cleared by a review conducted by Penn State University. Dr. Phil Jones, Director of the University of East Anglia’s Climate Research Unit (CRU), was cleared by a review conducted by the University of East Anglia, and also by a four-member “independent panel,” one of whose members was Prof. Geoffrey Boulton, a personage who had been on the faculty of East Anglia’s School of Environmental Sciences for 18 years, and who (prior to being placed on the “independent panel”) had been a vocal defender of Dr. Jones’ actions regarding Climategate.

Right-wing global-warming-deniers, of course, have decried the results of these reviews as a “whitewash,” pointing out, among other things, that Penn State and East Anglia both continue to receive tens of millions of dollars in federal “research” funds so they can continue to prove that global warming a) exists, and b) is man-made, thus suggesting that these institutions were determined to acquit their star grantsmen of scientific misconduct no matter what the objective findings. This kind of whitewash, they say, not only supports the global warming “hoax,” but even worse, further undermines the integrity of the scientific process upon which so much of modern society so utterly relies.

Of course, if right-wingers are correct, then reversing modern society and putting us all back in the glorious horse-and-buggy days is the very goal of the global warming mavens. (DrRich, a student of history, is well aware of how difficult it must have been 110 years ago to walk the streets of New York City without ending up splattered with dung to your knees, and he wonders what life would be like today, navigating the highways and byways of America, if all 300 million of us were relegated again to modes of transportation that defecate nearly continuously.)

It must be admitted, by anyone who has perused some of the leaked e-mails sent and received by Dr. Jones (making it doubtful that any of the three review panels had actually done so), that from any really objective viewpoint the global warming experts had engaged in some very questionable behaviors, which appear to have been aimed at advancing their theories, and suppressing any opposition, by any means at their disposal. The e-mails depict Jones and prominent colleagues discussing how to “tweak” climate change data in order to hide such embarrassing climatic phenomena as the Medieval warming period, “the little ice age” that followed it, and the global cooling we’ve been seeing over the past decade. Including these historical temperature fluctuations in their data would make their famous hockey stick graph look less like a hockey stick, and more like the random profile of a mountain range. (And once Al Gore won an Oscar for showing slides of the hockey stick, that was not an option.) They also collaborated to “control” the peer-review process so that only the “right” peers would be doing the reviewing, and the “wrong” peers would be cut off altogether. And, as a final deft touch, they all shared electronic high-fives when a noted global warming skeptic died unexpectedly.

Then, of course, just a few days after the embarrassing e-mail leak, the CRU was forced to admit (thanks to Britain’s Freedom of Information act) that they had, apparently intentionally, destroyed all the raw temperature data upon which their elaborate computer models were based. (They say they ran out of space to store it, apparently failing to recall the many forms of magnetic storage readily available to scientists today). The destruction of this data utterly precludes other scientists from checking, and attempting to reproduce, the critical predictive model upon which the theory of man-made global warming largely rests.

Oops.

This inconvenient truth renders their climate change model a black box. It places the rest of us in the position of having to “just trust” the global warming experts, upon whose work (for instance) President Obama bases his proposal for a fundamental change in our economy, our way of life, and our foundational political philosophy.

So it is perhaps somewhat understandable that right-wingers object so vociferously to the alleged “whitewash.” Their general complaint seems to be that the scientific process should always be pristinely unbiased, and that the gross bias so clearly displayed by global warming experts in this case not only corrupts the case for global warming, but also corrupts the scientific process itself, to the extent that every scientist in the world should be screaming for the heads of the miscreants, and indeed, must do so, to salvage the very legitimacy of science.

DrRich is sympathetic to the argument that the implications of Climategate are troublesome, but not because the climatologists have behaved in a terribly biased way. Biased thinking within a scientific debate is not only common practice, but also it is a critically important part of the process. Raw contention between very biased scientists with very different viewpoints is how we get scientific progress in the first place. DrRich is not even disturbed that the currently-entrenched global warming experts have used their position of relative strength to suppress the upstarts who dared to oppose them. That’s also pretty much standard behavior in the academy, and it, too, serves a useful purpose.

Rather, what’s troublesome about the global warming controversy is that outside authorities of incredible power have taken an extraordinarily strong position in the scientific debate, and have lent their massive influence to one particular side. Whenever this sort of thing happens, the “winner” of the scientific contest is often not determined by superior scientific merit, but by other factors.

Scientific progress works like this: A new theory is conceptualized to explain some phenomenon, usually by a whippersnapper of one variety or another. The entrenched experts, whose careers, reputations, social status, incomes, and sexual fulfillment are based on the old conception, find the new theory to be absurdly wrong (or in some cases heretical), and probably dangerous. Since preserving the “truth” is the highest calling of all, the experts engage in every device they can muster (from “controlling” the peer-review process to burning heretics at the stake) to see that the truth (as they define it) prevails.

To the uninitiated – and certainly to the upstart whippersnappers – this process seems primitive and unkind. But actually it is quite useful and practical, and in the long term is very beneficial to mankind. For most of the new theories thought up by whippersnappers are, in fact, garbage. In order to break through the imposing barriers of bias constructed by the entrenched experts, the novices really have to believe in what they are espousing, and their new theory, ultimately, has to actually offer some substantial improvement over the currently accepted one. The whippersnapper, if very lucky, finally becomes the foundation of a new generation of experts – and the process begins all over again. Hence, science progresses. The process is geared toward the gradual discovery of truth, and not toward the nurturing and vindication of whippersnappers. And eventually, truth always does prevail – and often it does so within just a few generations.

In the short term, of course, this process can look very messy and unfair. It is certainly subject to great bias. In fact, we take pains to set up the accepted experts with lots of grant money, prestige, titles, &c. precisely to make sure they’ll do everything they can to preserve the status quo. We do this so that when the paradigm actually shifts, it shifts because the merits of the new paradigm are sufficient to overcome all the bias – and not because of a whim. This process keeps science – and society – from being whipsawed this way and that.

Where the process breaks down is when a powerful outside influence – say, a religion or a government – firmly takes a side in the scientific debate. For example, just ask any of the would-be astronomers from the time of the pre-Renaissance Popes how well the scientific process of competing biases worked out for them.

It seems apparent, to DrRich at least, that  most of the world’s governments, including ours, find that the bias of the global warming experts very nicely aligns with the historical bias of governments, which is to say, accruing ever more power over the endeavors of the people.  It may possibly be for this reason that governments have thrown in – body and soul – with this side of the debate, to the extent that “global warming” has now become largely sacrosanct. Man-made global warming is officially deemed (like the 2011 U.S. Budget) to be  “settled science,” and is beyond reasonable question. No new scientific evidence to the contrary is admissible. Competing viewpoints are, in fact, heretical. And even when gross evidence of academic misbehavior on the part of global warming experts is revealed, that evidence is excused, paved over and ignored.

This mindset is the only one that fully explains the tone and the content of the Climategate e-mails, and the subsequent exoneration of the climate scientists who wrote them.

Most readers, DrRich expects, agree with him to this point. (For, how could it be otherwise?)  But, you may be asking, what does any of this have to do with healthcare, or more specifically, with healthcare rationing?

As we enter into a new era of healthcare, where medical decisions will be taken out of the hands of imperfect physicians and entrusted to panels of federally-sanctioned (and thus pretty much infallible) experts, who will analyze the available data and construct the guidelines of behavior by which all physicians will henceforth be judged, we ought to keep the problem of unbalanced bias in mind.

Today we have a healthcare system in which competing interests, and their competing biases, battle for prominence. The process is messy, ugly and often unfair, but with long-term results that are generally reasonably favorable. Or at least, the damage is generally contained.  But we are headed toward a healthcare system in which only one great interest – that of our government, with its overwhelming bias toward cutting the cost of healthcare – will predominate.

A great fallacy under which many of us labor is that the government has no strong biases, and that a process overseen by the government will be inherently far more “fair” than a process that incorporates the biases of for-profit enterprises. But in truth, the government is the biggest, meanest, special interest of all. And like all sovereign authorities, this one is not only able to, but is expected to get the results it deems necessary by the measured application of violence.

For those who believe any government, anywhere, which has total control over any human enterprise can still behave fairly, DrRich begs you to please have another look at history. When we allow government (and its agents) to have the only say over medical decisions, then those medical decisions will be made with all the robust, open-minded, free, give-and-take exchange of ideas we are seeing from the global warming experts today. And while medical progress – like progress in general – cannot be forever halted, it will become as sclerotic as the scientific progress enjoyed by those pre-Renaissance astronomers.

The scientific process will always be biased. Where we invite serious damage is where we admit only one form of bias, and forcibly stifle all the rest. It’s bad for climate science, and it will be bad for healthcare.
________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Now on Kindle!

Since the late 1990s, American physicians have labored under a set of tortuous documentation requirements imposed upon them by our government. The E&M guidelines (for “evaluation and management”), apply to the documentation that physicians are now obligated to provide in support of their Medicare billing. The E&M guidelines, first instituted in 1995 and revised in 1997, were part of the Clintons’ great fraud reduction initiative. Ostensibly, the strict documentation requirements reduce the opportunity for fraudulent billing.

While doctors initially railed against the E&M guidelines, they now suffer them in relative silence. The E&M guidelines have become, in fact, just one more hurdle which doctors must navigate as they pick their way through the vast obstacle course that now defines the practice of American medicine. Indeed, younger doctors accept the odious documentation requirements as a matter of course, knowing nothing better, just as children born into the direst third-world slums accept their abject poverty without notable complaint.

But occasionally, physicians of a certain age, dimly remembering how it ought to be, will still complain about these guidelines. One of these is revered fellow blogger DB, who (unlike DrRich) is still in the trenches, and must deal with – and try to teach trainees how to navigate through – this abomination on a daily basis. Accordingly, DB is periodically moved to remind us of what he graciously believes to be the unintended consequences resulting from the E&M guidelines, which is to say, DB seeks to remind us that current medical documentation requirements get in the way of good and efficient patient care.

For some, however, even this sort of mild-mannered, exceedingly polite objection is not to be countenanced. One of DB’s correspondents fired back at him:

“The templates are there to serve as a guide, not a hinderance. If you don’t like your “guide” then work to change it. You shouldn’t look at this “guide” as a form of billing, but rather as a guide in making sure you have covered your bases when seeing the patient. Proper documentation can lead to quality care and positive patient outcomes.”

This, indeed, is the official government position on E&M guidelines. It is so official, in fact, that it moves DrRich to wonder whether Cass Sunstein has actually implemented his well-documented anti-conspiracy strategy, and thus has dispatched armies of government-approved agents to monitor and actively counter “untruths” which are unfriendly to government aims, wherever they are found.

In any case, DrRich is not as polite (or as circumspect) as DB, and so he will say it outright.

The E&M guidelines were established for the specific purpose of controlling the behavior of physicians, to further the goals of covert rationing.

First and foremost, they create a Regulatory Speed Trap of the first order, so that with each and every patient encounter the item that will be foremost in the physician’s mind is not the needs of the patient, but in filling out the complex documentation in such a way as to avoid the appearance of committing a fraud. In practical terms, this means filling out the documentation so as to blend in with the masses, so that one’s records will be passed over by the sharp eyes of the greedy forensic accountants (who are paid by commission for detecting instances of substandard documentation, which are now construed as “fraud”), or even worse, by the sophisticated software now being deployed to detect ever-more nuanced gradations of “outliers.”

A classic post by The Happy Hospitalist describes the mysteries of E&M documentation better than any other attempt DrRich has seen. HH’s description of the documentation hoops through which physicians now must jump is detailed enough that it’s actually difficult to read. Which is the point.

Through their utter opacity and complexity, only partially reflected by the 48 pages of dense prose that comprise them, the E&M rules (for “rules” is what they are) in fact greatly magnify the doctor’s opportunity for making inadvertent documentation errors, and thus of producing a “fraudulent” bill. HH’s post nicely demonstrates how writing a progress note according to the E&M rules requires assembling a complicated set of “elements” from Column A and Column B, as from a Chinese menu, for each of four subject areas of the patient encounter – the history, the physical exam, the assessment, and the plan. Then somehow, one must translate the result (which reads like – and often is – a computer-generated form letter) into the proper, fully-supported billing code.

Even if this mess led to a straightforward means of determining proper billing codes (which it does not), it results in a medical progress note that is virtually undecipherable. This means that when another doctor (or even the same doctor on a different day) tries to read the progress notes to figure out what’s been going on with the patient (which used to be the point of medical progress notes, before they became primarily a vehicle for auditors), they cannot. Compliance with the E&M guidelines can thus actively confound patient care.

When the E&M guidelines were first introduced, they were recognized immediately by doctors as a complete abomination. Indeed, the great hue and cry from angry physicians (and the arrival on the scene of a new Republican administration) caused the Secretary of HHS to appoint a special commission to review the E&M guidelines in 2001. The commission concluded that indeed, the E&M guidelines were entirely counterproductive to patient care, and in June, 2002 voted (20-1) to recommend abandoning them altogether.

But HHS declined to follow the recommendations of its own commission, instead leaving the E&M guidelines in force “temporarily,” and vaguely promising to revise them “soon” in order to make them less dangerous to patient care – knowing full well that the saurian lassitude of the bureaucracy would easily outlast the fleeting indignation of the medical community.

(This simple example ought to teach us how difficult it will be to roll-back any of our new healthcare reforms in the future, even ones that are officially deemed to be harmful.)

Accordingly, not only has HHS failed to take (or, alternately, succeeded in not taking) steps to revise the E&M guidelines, they also have vigorously pressed forward with audits and prosecutions for the federal crime of healthcare fraud, based on physicians’ inadequate compliance with them. And, as the bureaucrats must have predicted, there has not been any substantial noise from doctors about revising these guidelines for several years now.

What’s more, there never will be. Save for the occasional exhortation from an old fossil (sorry, DB), the E&M guidelines have been fully absorbed into modern medical practice. They have become normal.

Accordingly, a multi-million dollar industry has sprung up to help physicians better comply with these coding guidelines. Physicians across the country are spending the time and money allotted for their continuing medical education learning to become better accountants, rather than better physicians.

Which brings DrRich to his last point: It is not actually possible to follow the E&M guidelines to anyone’s satisfaction.

There is, in fact, no “correct” way to code, because correct coding is impossible. This verity was proven a few years ago when a group of specialized government-sanctioned coders took a sample of typical doctor-patient visits, coded them according to their own E&M guidelines – and they all got different answers. (The results of this study were published in the Annals of Emergency Medicine in September, 2002.)

Obviously, then, since there is no “right” way to comply with the coding rules, any doctor toward whom the fickle finger of fate points the Feds is very likely to be found guilty of abuse, if not outright fraud. And what we’ve got here is a well-documented, openly acknowledged, peer-reviewed and published Regulatory Speed Trap.

Here’s what happens to doctors who are found to commit coding abuse (which is to say, to any doctors who are visited by Federally-sanctioned auditors):

1) A small sample of their patients’ charts is audited.
2) The error rate (with the auditor determining retrospectively what an error is) is calculated for that sample, then that rate is applied by extrapolation to all the Medicare billing the doctor has done for the past 6 years (the statute of limitations).
3) For each violation in coding the doctor is calculated to have committed during those six years, the doctor must pay a) triple the amount of restitution, and b) $11,000.00 (per coding violation).

It is not unusual for audited doctors to be hit with hundreds if not thousands of coding violations over a 6-year period, and the fines will almost always amount to well over 7 figures, if not 8. Even rich doctors usually can’t afford that kind of damage. However – if it’s just abuse the doctor has committed and not fraud – often the Feds may offer a settlement deal in the low 7 figures.

And here’s what happens if the coding violations are judged to be fraudulent (which, unfortunately, often appears a somewhat arbitrary designation):

1-3) All the above.
4) Jail

In summary, DB makes a very legitimate point, and has made this point several times over several years. Namely, the E&M coding rules are highly counterproductive to patient care. They produce medical records that are fundamentally undecipherable regarding actual medical content, even by medical professionals; and they distract physicians, with every patient encounter, into a fraud-avoidance exercise.

Sadly, however, DrRich does not believe that merely pointing out the harm being caused to thousands of patients each and every day by the E&M guidelines will do any good. Believing that it might do some good to call the Feds’ attention to it assumes that the harm is an unintended consequence, or at least, that it would be considered too high a price to pay.

This, DrRich feels obligated to reiterate, is demonstrably not the case. The Feds know that the E&M guidelines are harmful to patient care. Their own commission came to that very conclusion in 2002. The Feds know that failing to comply perfectly with the E&M guidelines in each and every case does not really indicate fraud and/or abuse, but is the necessary outcome when you institute a complex set of rules that not even the government’s own coders can interpret. Reminding the Feds of these facts, in public, may make them angry, but it will not change their position on E&M guidelines.

That the Feds continue to impose the E&M guidelines on physicians, despite the harm that they know this causes, tells us something very important about their underlying motives. When you are in the business of covertly rationing healthcare, controlling the physicians is Job One. And as George Orwell observed for us, when you want to control the behavior of some population, a critical step is to control the mode, the rules, and even the very language of communication.

That physicians continue to comply with such oppressions, despite the harm they know this causes, and (with notable exceptions) without serious complaint, tells us something important about them, too. DrRich would rather not say what that is.

________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Now on Kindle!