Podcast:

Health insurance premiums all over the country are rising at rates that, only a year ago, were rare, and when they occurred, provoked angry and threatening letters from Secretary Sebelius. Increases in premiums of 40% are not uncommon this year, and businesses across the land (which otherwise might be inclined to do their patriotic duty, as defined by President Obama, and hire some people) are suffering because of it.

Republicans, of course, already smell blood in the water. A federal judge has declared Obamacare – the entire law – to be unconstitutional, and has given the administration only a limited time to apply for a stay of his ruling. President Obama himself seems to be faltering on the individual mandate, telling states that they can forgo this mandate – if, that is, they can come up with an alternative plan that does everything the President claims Obamacare is supposed to do.*

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*States can’t really accomplish this, of course, so the President’s offer is empty. DrRich thinks that he is advancing this idea in order to make the argument, in court, that the mandate is not really a mandate, since, as he’s just made plain, it’s merely an option.
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And now, Republicans gleefully point out, thanks to Obamacare health insurance premiums are rising faster than they ever have before, at rates that threaten to make our jobless recovery remain jobless forever. “Look at the damage Obamacare is already doing,” they’re telling us, “and most of its destructive provisions don’t even kick in for three more years.” The increase in insurance premiums will soon be felt – directly or indirectly – by every American who has health insurance. It will be a huge boost, Republicans think, to their efforts to get rid of Obamacare.

In an action that will undoubtedly surprise those many experts who persist in believing that Obamacare represents a major defeat for insurance companies (and who therefore must live in a perpetual state of surprise regarding many things about the healthcare system), the insurance industry is vociferously denying that their current premium increases have anything to do with Obamacare. According to the New York Times, for instance, Vincent Capozzi, an executive at Harvard Pilgrim, insists that only 1% of the premium increase this year is caused by Omabamacare (mainly its requirement for free coverage of preventive services). The insurance industry, according to the Times, maintains that “premiums are rising primarily because of the underlying cost of care and a growing demand for it.” That is, the cost of healthcare is accelerating thanks largely to our aging population and the adoption of expensive new technologies.

Whatever it is that’s making premiums go up, the industry asserts, it’s not Obamacare.

To understand what’s really going on here, DrRich asks you, Dear Reader, to put yourself in the place of a health insurance CEO in early 2011. After a long, hard fight, in which you had to debase yourself in public several times (in order to play your assigned role of Villain in the Obamacare set-piece), you are now a mere 33 months from Nirvana. In January, 2014, the individual mandate kicks in, and you will reap your reward of tens of millions of new subscribers, subsidized by the government, and thus you will have your long-coveted One Last Windfall. A year or two after that, once you have blown through this last windfall, you will become a public utility. It is not a glorious ending to your once-arrogant industry, but it is far better than the oblivion which otherwise would be your fate.

Common wisdom (such as that employed by most of those perpetually nonplussed “experts” to whom DrRich previously referred) might suggest that your best course would to be to lie low for the next 33 months, to remain as unobtrusive as possible so as not to upset the apple cart, in a word, to keep any increases in your premiums down to an unremarkable rate. But you are smarter than that. You understand that while instituting outlandish premium increases at this juncture is indeed risky, you’re still walking a tightrope, and keeping your premium increases to a more reasonable level is equally risky.

There are two good reasons for you to raise your rates right now to a truly stunning degree. First, of course, you only have three more years to control your own insurance premiums. Once Obamacare is fully actuated, and the mandates are applied, stringent controls will be placed forevermore on your ability to raise your premiums. So naturally, you need to establish as high a baseline as possible during these next three years.

Perhaps more importantly, you need to place a shot across the bow of the Republicans. You need to let them know that if they manage to repeal Obamacare, either legislatively or through the courts, they will have a tiger by the tail. “Just look at us!” you are saying. “Today, before Obamacare even kicks in to any appreciable degree, we are forced to engage in these truly ridiculous premium increases. Increases like this will drive subscribers from our rolls, and will bring the wrath of the administration down upon our heads, but we do it nevertheless, as we have no choice. Look upon us, Republicans! If you succeed in repealing Obamacare, just look at what you will inherit! The alternatives you propose to Obamacare all hinge on a robust health insurance industry, but we are not robust – we are decrepit, we are dying. Our business model is so obviously broken that today we are behaving suicidally. We, your presumed partners in your post-Obamacare healthcare system, are the living dead. So think twice, Republicans, before you go any further!”

Just how well the insurance companies will succeed by this method in slowing the Republicans’ efforts to overturn Obamacare, one cannot say. Probably not much. But inasmuch as Obamacare is utterly necessary for the survival of the insurance industry, if this method fails DrRich is confident they will come up with something better.

Podcast:

In his last post, DrRich suggested that the Guideline Wars (i.e. the bloody battles over who gets to establish the patient-care guidelines that determine which patients will get which medical services, and which medical specialists will get to provide them) are about to enter the Obamacare phase, in which those who make the guidelines will no longer be medical professional organizations, but agents of the federal government. DrRich helpfully labeled the various guideline panels provided for by the Obamacare legislation as the “GOD panels” (for Government Operatives Deliberating), in order to avoid using the more inflammatory “death panels” terminology favored by certain less sophisticated commentators.

In addition, DrRich pointed out that his own tribe of medical specialists – the cardiologists – may perhaps be in a better position than most other physician tribes to manipulate the deliberations of these GOD panelists. The cardiologists would attempt such manipulations, DrRich suggested, by “pre-spinning” certain critical data from clinical trials, before that data is taken up by the government panels.

From their long experience in fighting the Guideline Wars, cardiologists understand that data from clinical science does not invariably lead to a fixed conclusion (as most proponents of evidence-based medicine seem to believe), but rather, can often be shaped into whatever sort of conclusion one might want to reach. Just as different primitive cultures discerned different constellations when they looked up into the same night sky, so will different groups of experts come to different conclusions when they look at the same clinical data.

Accordingly (DrRich submits), cardiologists have already embarked on the task of pre-spinning the data, such that when the GOD panelists look for the first time up into the vast and chaotic sky of clinical evidence, they will have in hand a map of the constellations as seen by the cardiologists.

To illustrate what he means, DrRich calls his readers’ attention to the SYNTAX trial, a clinical trial designed by cardiologists and their industry partners for the purpose of reaching a specific conclusion, but which (unfortunately for cardiologists) reached the opposite conclusion. If the data from the SYNTAX trial should ever fall into the hands of the GOD panelists (or any other guideline panels) in a pristine fashion, it could spell disaster. So the cardiologists have spent nearly two years attempting to make the data say what they want it to say, and today, after continuously massaging the data, issuing press release after press release, making presentation after presentation, and publishing academic paper after academic paper, it would be at least a little surprising if the God panelists, surveying this body of pre-spun data, would fail to produce clinical guidelines which provide the cardiologists at least some of what they’re after.

The SYNTAX trial randomized 1800 patients with complex coronary artery disease (i.e., CAD that produces either significant blockage in the left main coronary artery, or severe triple-vessel disease) to therapy with either bypass surgery or drug-eluting stents (DES), and assessed their long-term outcomes.

In general, patients with stable CAD (i.e., those who are not currently having a heart attack or unstable angina) do just as well with aggressive medical therapy as they do with invasive therapy. People like the ones enrolled in SYNTAX, however, are the exception to this rule. That is, patients with either of these two specific patterns of complex CAD have been shown to have improved survival if they receive bypass surgery. Indeed, these patients represent a virtual “last stand” for cardiac surgeons – they are nearly the only patients cardiologists (at least some cardiologists) still feel obligated to refer for bypass surgery. And, as one might expect, in their decades-long turf war with cardiac surgeons (a war from which they will not desist until they see the great majority of cardiac surgeons seeking jobs as beer vendors at sporting events), cardiologists have long chafed at this singular remaining obligation to refer.

Accordingly, SYNTAX, a study instigated by cardiologists and sponsored by Boston Scientific (a manufacturer of DES), was intended to show that with modern cardiac stents, stenting yields outcomes that are not significantly inferior to bypass surgery in these patients. Specifically, that is, SYNTAX was designed as a “non-inferiority trial.” This was certainly a modest goal – some might say too modest – but a positive result would enable cardiologists (the gatekeepers to all invasive CAD therapy) to simply keep these patients for themselves, just as they now do with all the other CAD patients. The SYNTAX trial asked the question, “Do I really have to refer these patients to the cardiac surgeon?” And the desired answer was, “No, it apparently is not statistically provable that you absolutely have to refer them, one supposes.” Judging from the study design, that answer would have been plenty rigorous enough for the study designers.

Alas, however, when the one-year follow-up data for the SYNTAX study was analyzed, the results turned out to be negative; stenting was significantly inferior to surgery. The endpoint of the study was a composite called MACCE (Major Adverse Cardiac and Cerebrovascular Events), and in this study included death, heart attack, stroke, and the need for more revascularization procedures. The bottom line is that in SYNTAX, the risk of MACCE was significantly higher for stenting than for bypass surgery. The study failed to meet even the modest non-inferiority goal the cardiologists had devised for it.

The one-year data for the SYNTAX trial was published in the spring of 2009 in the New England Journal of Medicine, just as the battle over healthcare reform was taking shape, and nearly six months after Sarah Palin had reported her mysterious vision of death panels. But whether one wanted to call them death panels, GOD panels, or panels of distinguished monkeys, it was clear by the time SYNTAX was published that the government, and no longer the physicians’ own specialist organizations, would be manufacturing all clinical guidelines in the near future. So disaster loomed.

But, the cardiology community quickly rallied, and launched into a concerted effort to spin the results of SYNTAX from a disaster into a victory, or at least, to something akin to victory. And the efforts of the cardiologists in this regard have been impressive over the last 18 months.

Within minutes of the publication of the original SYNTAX article, scores of press releases were launched, and scores of “experts” were dispatched to give interviews, implying that the SYNTAX study was a major, ground-breaking victory for stenting.

For instance, here’s the link to an article in the New York Times (subsequently reproduced in hundreds of newspapers around the country) entitled, “Heart Stents Found As Effective As Bypass For Many Patients.”

And here’s a triumphant press release from Boston Scientific, the study’s sponsor, in which the negative overall results of SYNTAX are buried deep within the 6th paragraph (following all kinds of positive-sounding fluff), and are difficult to locate even if you are specifically looking for them.

And here’s the more-than-triumphant press release from one of the leading clinical sites for the SYNTAX trial, which reads, in part:

“At NorthShore, we experienced stunning outcomes [emphasis DrRich's] in patients whose only option would have previously been bypass surgery,” said Ted Feldman, M.D, F.S.C.A.I., Director of Cardiac Catheterization Laboratory, NorthShore University HealthSystem, and a lead investigator of the trial. “The data in this study will provide cardiologists with additional information as they determine treatment therapy for patients with complex CAD.”

Most remarkable of all, we have the spectacle of the lead author of the SYNTAX paper, Dr Patrick W Serruys himself, telling Heartwire immediately after publication of the paper, that the paper’s concluding sentence (i.e., “CABG as compared with PCI is associated with a lower rate of MACCE at one year among patients with three-vessel or left main coronary artery disease (or both) and should therefore remain the standard of care for such patients.”), is just plain wrong. Serruys declared that this concluding sentence actually “is not the essence of the trial.” He only allowed that concluding sentence to appear in the paper, he said, “because the New England Journal of Medicine wanted something more conservative.” (Apparently, having the paper appear in a prestigious journal overrode the necessity of having the paper accurately reflect what the authors meant to say.)

In any case, Serruys insisted (despite the conclusion expressed in his ink-not-yet-dry paper) that many patients like the ones enrolled in the SYNTAX trial can safely be treated with stents, and indeed, he announced that he and his co-investigators were hard at work teasing apart the SYNTAX data in order to develop a so-called “SYNTAX score,” that would help cardiologists determine which patients they can treat themselves, without referring them for surgery. So indeed, despite the negative results, and despite the conclusion written in their own paper, the SYNTAX trial was immediately spun by key trial participants themselves into a win (while not a complete victory, still a win).

Before his readers come down too hard on the cardiologists for such behavior, DrRich feels obligated to point out a partially mitigating truth. Namely, cardiologists believe to the depths of their souls, notwithstanding the largely negative body of medical literature to the contrary, that stenting coronary artery blockages – in virtually any configuration and any clinical situation – saves lives. And if they haven’t been able to prove that yet, it’s just because of the vagaries of clinical research. One must not let spurious results from imperfect research block the Truth, lest one allow great harm to come to humanity.

The results of the SYNTAX trial must simply be wrong, cardiologists believe, and so they would be gravely harming patients if they did not take whatever steps were necessary to render the results of SYNTAX more favorable to stenting. To do otherwise would cause thousands of clinicians to make inappropriate decisions.

In this way, DrRich believes, cardiologists are no more guilty than are Progressives, another category of humans who believe with their hearts and souls in something that is simply not true (in the case of Progressives, that the great mass of humanity will willingly suppress their own individual interests in favor of the interests of the collective). Like the Progressives, cardiologists are often very nice, well-meaning, sensitive and compassionate individuals, and some of them would even be fun to go out with for a beer.

In other words, DrRich pleads, cardiologists are not being particularly evil in spinning the SYNTAX trial results; they are simply doing what comes naturally, and what they deeply believe to be the right thing.

This is why the SYNTAX investigators were convinced that, buried within the vast body of clinical data the SYNTAX trial has generated, there simply MUST be something useful to cardiologists. Accordingly, the SYNTAX investigators dived head-first into the proverbial room full of manure, enthusiastically digging for the pony which simply must be in there somewhere.

And indeed they quickly found their pony.

And here it is: While a straightforward analysis of the SYNTAX study shows that bypass surgery wins hands down over stenting, if one delves a bit deeper into the data, one finds that one of the components of the MACCE endpoint – the incidence of stroke – was statistically higher among the patients randomized to bypass surgery. One also finds that the incidence of needing revascularization during follow-up was higher in the stent patients. So, taking these two interesting observations together, the cardiologsts have concluded that patients receiving bypass surgery are trading a reduced need for subsequent revascularization for an increased risk of stroke – a bad trade indeed. Therefore, despite the overall results of the study, they have concluded that stents are better than bypass surgery for at least some patients. (And they promised to discover for us, during the data-mining exercise from which their “SYNTAX score” was subsequently invented, which patients those are.)

And this – the reduced incidence of stroke seen in the stent patients – is the basis for the celebratory statements which were issued by the SYNTAX investigators upon publication of their original paper.

DrRich agrees that, as a general proposition, he would probably rather have an extra invasive cardiac procedure than a stroke, and suspects that most people would say the same thing. But before we all buy what cardiologists are selling here, DrRich would like to make a few observations.

First, the results of the SYNTAX trial are the results. Stenting did not meet even its modest non-inferiority endpoint, and it failed to meet it by quite a lot. Once the pre-designated endpoint of a randomized clinical trial is determined, any remaining observations that can be gleaned from the large amounts of data invariably generated by such trials must be viewed as inconclusive, as merely hypothesis-generating. Such observations are not to be regarded as having sufficient statistical surety to vastly change medical practice, or to figure into evidence-based guidelines. So, another clinical study would need to be conducted to prove the hypothesis that strokes are less frequent with stenting than with bypass surgery in patients like these.

Similarly, the “SYNTAX score” – which indeed was generated and subsequently published as a “guide” for cardiologists treating patients with complex CAD, and which is therefore presumably being used today by cardiologists all over the world to select which of these complex patients they can just go ahead and stent rather than refer for bypass surgery – has no business being incorporated into clinical practice. An exercise like this – in which investigators comb retrospectively through the clinical data, selecting out patients who had good results with stenting, then devising a group of characteristics that appears to differentiate them from those who did not – cannot possibly yield a validated, widely-applicable clinical tool. If they want to claim that their SYNTAX score is clinically useful, they need to conduct another randomized clinical trial to test that hypothesis.

Next, and most remarkably, there’s the almost universally-ignored fact (reported by Dr Friedrich W Mohr, co-principle investigator of the trial), that among patients assigned to bypass surgery in the SYNTAX trial who experienced a stroke, nearly half of them had their strokes PRIOR TO SURGERY. What this means is that, in reality, the bypass surgery itself did not cause those strokes, a fact that ought to cause serious damage to the chief assertion of the stent-proponents. This fact alone turns their pony into a pig. The claim that stenting instead of surgery would have avoided these strokes is largely, if not entirely, spurious. Indeed, if anything, the fact that patients “randomized” to surgery apparently had a lot of strokes in the brief period of time between the act of randomization and the surgery itself ought to make one question whether the selection of therapy was really and truly random, or whether, somehow, patients who looked particularly sick got sent preferentially to the surgeons.

And finally, the clinical choice as it has been starkly painted by many proponents of stenting – that the real trade-off in choosing between stenting and bypass surgery in these patients is the choice between the higher risk of stroke with surgery versus the higher risk of revascularization with stenting – is incomplete and misleading. Presenting the choice in this way clearly favors stenting, and this presentation entirely explains the positive press releases and subsequent media coverage of the SYNTAX trial. But this is not a valid comparison of risks for several reasons:

1) As noted above, the actual risk of stroke posed by performing bypass surgery in the SYNTAX trial has been substantially overstated for public consumption (by implying that the surgery caused those strokes, when half occurred prior to surgery).

2) Surgeons in the SYNTAX trial most often did not employ newer techniques now in routine use, such as off-pump surgery and LIMA grafts, both of which can substantially reduce the risk of stroke and other embolic phenomena.

3) Re-occlusion of the involved arteries (which occurred about equally in both groups in this study, and which spokespersons for SYNTAX seem to brush off as not such a big deal), is an entirely different phenomenon in patients who have received DES than it is in patients who have had bypass surgery. After bypass surgery, re-occlusion tends to occur gradually, and the patient generally experiences recurrent symptoms of angina. But in DES, re-occlusion much more commonly occurs acutely, and catastrophically, leading rapidly to permanent cardiac damage and often, to sudden death.

4) Item # 3 might explain why the composite endpoint of “death, heart attack and stroke” was equal in both groups, even though stroke was significantly higher in the surgery group. That is, in order for the math to work out, the remaining dyad of “death and heart attack” necessarily must have been higher in the stent group. As far as DrRich can tell, this point has never been discussed in public.

5) In order to avoid the catastrophic re-occlusions seen with DES, cardiologists now insist that their DES patients take long-term, even life-long, Plavix, a powerful blood thinner. As the purveyor of a patient-oriented website on heart disease, DrRich cannot tell you how many distressed and stented-up patients have written to him with the following lament:

“My doctor put in one of those drug coated stents and has me on Plavix. He says if I stop the Plavix I could die, and won’t let me stop it for any reason. But I need my gallbladder out because I keep having gallbladder attacks, and the last one gave me blood poisoning. My surgeon says I need the surgery but he won’t do it unless I stop Plavix, and my cardiologist says no stopping the Plavix for any reason. What can I do? Can they just take these stents out so I can stop the Plavix?”

There is no easy answer to this question, at least not that DrRich can find. The DES patient commonly is left in the middle of a pissing match between surgeon and cardiologist. The fear of the cardiologist is that when one stops Plavix, there is a risk of sudden, catastrophic thrombosis of the coronary artery. But surgeons simply cannot operate safely on patients taking this drug. Few cardiologists seem to explain this to their patients before placing DES.

And more to the point at hand, none of the cardiologists spinning the SYNTAX trial are explaining to the public the implications of long-term Plavix. Even if their claims that stenting yields significantly fewer strokes turned out to be accurate, the choice here is clearly NOT a simple one between a higher risk of stroke on one hand, and a higher risk of needing “revascularization” (if they survive the re-occlusion, that is) on the other. There’s a lot more to think about than that, and cardiologists who imply otherwise are being either disingenuous, or delusional.

Just last week, SYNTAX investigators reported on the three-year outcomes in patients enrolled in the trial. The results, similar to the one-year outcomes, remain strongly in favor of bypass surgery at three years, and indeed, the incidence of stroke in stented patients has “caught up” with the incidence of stroke in the surgery patients.

This persistently bad news still does not really phase the cardiologists, who are now saying that the results of SYNTAX don’t really apply any more in any case, because drug-eluting stents have been improved since the trial was done.

It would appear that the cardiologists are going for some sort of official announcement to the effect that that the results of SYNTAX are, for practical purposes, indeterminate, and that what is needed is a new clinical trial, in which patients randomized to DES will receive the latest generation of stents. (Since there is a new generation of stents every year or so, this entire process can be repeated as needed until the cardiologists finally get the results they’re looking for, at which point they can declare final victory and stop.)

Summary:

All medical specialists should take a lesson from the cardiologists. In an era in which specialist organizations will no longer be writing the clinical guidelines for their own specialty, it is necessary to aggressively pre-spin any important clinical data upon which the GOD panels will be deliberating.

Considering the SYNTAX trial as a case study, one sees how it is possible to take the most straightforward results from a very straightforward clinical trial and, if not turn a negative outcome into a positive one, at least introduce enough complications, nuance, spin and uncertainty to cause any self-respecting GOD panelist to hesitate in making a definitive pronouncement on those results. Then, if you couple all the uncertainty you’ve created with a loud call for yet another clinical trial – one that will take into account new equipment, new techniques, new scoring systems &c., and that promises to clear up all the confusion you’ve dug up as a result of the last clinical trial – then you stand a decent chance of at least getting a postponement on any new guidelines harmful to your cause.

And this, you neurologists, gastroenterologists, pulmonologists and all you other, less savvy medical specialists, is how one can manage the GOD panels.

Podcast:

It is quite popular for certain medical bloggers who count themselves as scientifically sophisticated to disparage so-called “alternative medicine.”

Indeed, some have built entire websites to demonstrate (Penn-and-Teller-like) that various forms of alternative medicine – such as homeopathy, therapeutic touch, the medical application of crystals, Reiki, naturopathy, water therapy, bio-photons, mindfulness training, energy healing and a host of others – are completely devoid of any scientific merit whatsoever; are pablum for the uneducated masses; are, in short, irreducibly and irredeemably woo.

These same bloggers are scandalized into virtual apoplexy by the fact that the NIH has funded an entire section to “study” alternative medicine, and worse, that some of the most respected university medical centers in the land now seem to have embraced alternative medicine, and have established well-funded and heavily-marketed “Centers for Integrative Medicine,” or other similarly-named op-centers for pushing medically suspect alternative “services”.

(An astounding list of prestigious institutions of medical science now sporting Centers of Woo is maintained by Orec.)

Until quite recently, DrRich counted himself among the stalwarts of scientific strict constructionism. He was truly dismayed that the NIH and some of our most well-regarded academic centers (under the guise of wanting to conduct objective “studies” of alternative medicine) have lent an aura of respectability and legitimacy to numerous bizarre ideas and fraudulent claims masquerading as legitimate medical practices. To DrRich, such developments were yet another clear and unmistakable sign of the End Times.

Furthermore, DrRich (a well-known paranoid when it comes to covert rationing) saw a more sinister advantage to the official and well-publicized support that government-funded institutions were giving to the alternative medicine movement. Namely, fostering a widespread impression among the unwashed rabble that alternative medicine is at least somewhat worthwhile (and plenty respectable) advances the cause of covert rationing. That is, the more you can entice people to seek their diagnoses and their cures from the alternative medicine universe, the less money they will soak up from the real healthcare system. With luck, real diagnoses can be delayed and real therapy put off until it’s far too late to achieve a useful outcome by more traditional (and far more expensive) medical means.

So, for several years alternative medicine was seen by DrRich pretty much as it is seen by all of the anti-woo crowd – as an unvarnished evil.

But in recent days the scales have fallen from DrRich’s eyes. He now realizes he was sadly mistaken. Rather than a term of opprobrium, “alternative medicine” may actually be our most direct road to salvation. Indeed, DrRich thinks that far from damning alternative medicine, we should be blessing it, nurturing it, worrying over it, in the precise manner that a mountaineer trapped in a deadly blizzard would worry over the last embers of his dying campfire.

What turned the tide for DrRich was a recent report, issued by the U.S. Centers for Disease Control and Prevention, estimating that in 2007, Americans spent a whopping $34 billion on alternative medicine. That’s $34 billion, for healthcare (in a manner of speaking), out of their own pockets.

The implications of this report should be highly encouraging to those of us who lament the impending creation of a monolithic government-controlled healthcare system, and who have been struggling to imagine ways of circumventing the legions of stone-witted, soul-eating bureaucrats now being prepared (Sauron-like) to descend upon us all, doctor and patient alike.

This is why DrRich has urged primary care physicians to break the bonds of servitude while they still can, strike out on their own, and set up practices in which they are paid directly by their patients. Such arrangements are the only practical means by which individual doctors and patients can immediately restore the broken doctor-patient relationship, and place themselves within a protective enclosure impervious to the slavering soul-eaters.

One reason so few primary care doctors have taken this route (choosing instead to retire, to change careers and become deep-sea fishermen, or simply to give up and become abject minions of the forces of evil) is that they do not believe patients will actually pay them out of their own pockets.

Well, ladies and gentlemen, this new report from the CDCP demonstrates once and for all that Americans will, indeed, pay billions of dollars from their own pockets for their own healthcare – even the varieties of healthcare whose only possible benefits are mediated by the placebo effect. DrRich believes that many of the people buying homeopathic remedies are doing so less because they believe homeopathy works, and more because they feel abandoned by the healthcare system and by their own doctors, and realize they have to do SOMETHING. The CDCP report, in DrRich’s estimation, reflects the magnitude of the American public’s pent-up demand for doctors whose chief concern is for them, and not for the demands of third party payers.

Perhaps more importantly, this new report implies that it may be somewhat more difficult than DrRich has thought for the government to outlaw private-sector healthcare activities. As DrRich has carefully documented, a government-controlled healthcare system will require the authorities to make it illegal for Americans to spend their own money on their own healthcare, thus rendering direct-pay medical practices illegal, and putting the final stake into the heart of the doctor-patient relationship.

But the rousing success of the alternative medicine universe will make such laws difficult to enact.

To see why, consider just how encouraging this new CDCP report must be to the third-party payers. Thanks in no small part to the efforts of the government (and the academy) to legitimize alternative medicine, Americans are spending $34 billion a year on woo. This amount indicates tremendous savings for the traditional healthcare system. The actual amount saved, of course, is impossible to measure, but has to be far greater than just $34 billion. Some substantial proportion of patients spending money on alternative medicine, had they chosen traditional medical care instead, might have consumed expensive diagnostic tests, surgery, expensive prescription drugs, and other legitimate medical services. Furthermore, those legitimate medical services (as legitimate medical services are wont to do) often would have generated even more expenditures – by extending the survival of patients with chronic diseases, by identifying the need for even more diagnostic and therapeutic services, and by causing side effects requiring expensive remedies. (While alternative medicine is famous for being useless, it is also most often pretty harmless, and tends to produce relatively few serious side effects – except, of course, for causing a delay in making actual diagnoses and administering useful therapy, but if you’re a payer, that’s a good thing.) So the amount of money the payers actually save thanks to alternative medicine must be some multiplier of the amount spent on the alternative medicine itself.

What this means is that payers (which, let’s face it, will soon mean the government) will be loathe to do anything that might discourage the success and growth of alternative medicine, and this fact alone may stop them from making it illegal for Americans to pay for their own healthcare.

Still, we musn’t be too sanguine about these prospects. Under a government-controlled system, the imperative to control every aspect of healthcare (in the name of fairness) will be very, very strong, and it will be very tempting to the Feds to declare at least some varieties of alternative medicine to be covered services.

But the alternative medicine establishment (bless it) will be largely impervious to government control. Practitioners of alternative medicine are expert at designing vague products and services whose techniques, theories, processes and protocols are fluid, nebulous and ill-defined. So if the Feds declare, say, homeopathy and therapeutic touch to be legitimate, covered services under the Fed’s health plan, why, the alternative medicine gurus will simply come up with entirely new forms of alternative medicine, specifically to remain outside the government plan. (New varieties of alternative medicine already appear with dizzying speed, and can be invented at will. No bureaucracy could ever hope to keep up.)

Therefore, as long as the central authorities depend on alternative medicine as a robust avenue for covertly rationing healthcare, the purveyors of woo will always be able to flourish outside the real healthcare system. And this, DrRich believes, represents the ultimate value of woo, and establishes why we should all be encouraging and nurturing woo instead of disparaging it.

DrRich has speculated on various black market approaches to healthcare which could be attempted by American doctors (and investors) should restrictive, government-controlled healthcare become a reality. But now, thanks to the success of alternative medicine, there is a direct and straightforward path for American primary care physicians to re-establish a form of now-long-gone “traditional” American medicine, replete with a robust doctor-patient relationship, right out in the open – the kind of practice where patients pay their doctors themselves.

Simply declare this kind of practice to be a new variety of alternative medicine. Likely, PCPs will need to come up with a new name for it (such as “Therapeutic Allopathy,” or “Reciprocal Duty Therapeutics”), and perhaps invent some new terminology to describe what they’re doing. But what’s clear is what they will be doing is so fundamentally different from what PCPs will be doing under government-controlled healthcare as to be unrecognizable, and nobody will be able to argue it’s not alternative medicine. In fact, it will seem nearly as wierd as Reiki.

The success of medical woo, in other words, can provide American doctors who want to practice the kind of medicine they should be practicing with the cover they need to do so. And this is why we must support medical woo, and celebrate its continued growth and success.

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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:

Many thanks to a loyal reader, Ivan from Montreal, for calling DrRich’s attention to a recent editorial in the New England Journal of Medicine, arguing for more dollars to go to “public health,” as opposed to “healthcare.” The editorial is by David Hemenway, Ph.D., director of the Harvard Injury Control Research Center of the Harvard University School of Public Health.

By “public health,” Hemenway appears to mean that branch of academics that deals with promoting the overall health of a community through organized societal efforts. Some effective public health efforts have included vaccination programs, improved sanitation, motor vehicle safety, draining the swamps, limiting public smoking, and the chlorination of drinking water. A few of these efforts have even been advanced by actual public health experts, such as those to which Hemenway refers.

Hemenway’s main argument is that society gets more bang for the buck with money spent on these kinds of public health efforts, than on money spent on healthcare for individual Americans, an argument which is almost certainly true.

But his conclusion, that the distribution of healthcare dollars should be adjusted accordingly, is spurious. All four of the specific arguments he gives to bolster his claim that public health is underfunded are insubstantial, and more importantly, the folks who have given us most of the wonderful public health benefits we all enjoy are actually not the public health experts whom Hemenway wants to fund.

First, Hemenway claims public health is under-funded because people are just too stupid to understand the importance of public health. Specifically, they are incapable of valuing and thus implementing actions whose benefits lie in the future (such as those provided by public health). Hemenway is quick to say that it is not peoples’ fault; they are built that way. He even gives a complex neuroanatomical explanation for the innate inability of folks to plan for the future.

So: This must be why Americans have never landed on the moon, and why they refuse to invest in cancer research, or to fund their 401(k) plans. As Ivan from Montreal points out, this must be why the great cathedrals were never built. Hemenway’s point here is so spurious on its face that DrRich must wonder if it reflects that baseline contempt for the mental capacity of the proletariat, which is so fundamental to Progressive thinking.

Secondly, Hemenway points out that the beneficiaries of public health (being the public) are not identifiable as individuals, and so we (the bovine masses) cannot bring ourselves to care about them, as we care about individuals such as, he suggests, Baby Jessica falling down the well. This additional deficiency of the proletariat puts public health at a major disadvantage.

It is indeed true that humans have more capacity to identify with individual stories than with “populations.” But this issue is not unique to the field of public health. Those raising funds for heart disease research, for instance, deciphered this mystery long ago – since statistics only gets you so far, you need to tweak potential donors’ emotions by advancing the story of the 12-year-old heart transplant recipient. If the academics in public health haven’t been able to figure this out – using the Baby Jessica story to advance their latest theories on well safety, for instance – whose fault is that? (If what Hemenway says is true – that the field of public health “relies almost exclusively on government funding,” that’s where the fault is. Being on the public dole greatly dulls one’s perceptiveness and creativity.)

Thirdly, Hemenway says, “in public health, the benefactors, too, are often unknown.”  That is, whereas medicine has its great public heros – Hemenway suggests DeBakey and Barnard – the great heroes of public health do not get their due. There are doubtless many heroes of public health – the inventor of the flush toilet comes immediately to mind – but unfortunately most of them remain anonymous. The flush toilet’s inventor, for instance, based on current archeological evidence, died in the Indus valley 4600 years ago. Indeed, many if not most of the truly impactful public health advances took place outside the ivory towers of the modern academy.

Hemenway struggles mightily to come up with an unsung hero for modern, academically-based public health, and – and undoubtedly wishing not to remind us of certain well-known, early20th century heroes of the academy who espoused eugenics as the most effective means of achieving public health  – offers up one Maurice Hilleman, who saved countless lives with his development of more than 30 vaccines. Now, DrRich completely agrees that Hilleman was one of the most important scientists of the 20th century, and probably was responsible for preventing more premature deaths than any other person in history, and, certainly, that he is an unsung hero. But it is a bit of a stretch for Hemenway to claim him for one of his own. Hilleman did his vaccine development as an employee of E.R. Squibb, and then, of Merck. That is, his research was funded by private industry, whose primary motive was filthy lucre. If Hilleman is a hero of public health (and DrRich agrees that he is), then his career is an argument for unleashing the capacity of the private pharmaceutical industry, rather than an argument for more government funding.

Fourth, Hemenway laments that public health efforts often meet with fierce opposition from well-placed interests. This is true. Limiting smoking in public places, for instance, required a sustained battle against powerful interests for decades. But here, Hemenway tips his hand a bit too much. He cites a study showing that having a firearm in the house is a risk factor for gun death, and offers up this rather obvious result to illustrate the important work which academic public health can offer, and to decry efforts to de-fund that kind of important research. Now, DrRich does not diminish the importance of research whose aim is to improve gun safety. But he does wonder why Hemenway could only come up with an example of productive research which is just a little more helpful than, say, a study revealing that automobile deaths are more frequent in the U.S. than in Romania (where ox-carts remain a chief mode of transportation). If DrRich were grading this editorial request for funding as a formal grant proposal, he would take points off for the effectiveness of the applicant’s (that is, academic public health’s) prior work.

Hemenway’s fundamental sin is conflating “real” public health with whatever the people with degrees in “public health” are doing. “Real” public health consists of flush toilets, water treatment, draining swamps, pest control, well-lit streets, and the like, and tends to have a lot more to do with good civil engineering and fundamental medical research than with “academic” public health.

Some of what the modern experts in public health are doing, DrRich suspects, is quite important and is worthy of funding. But just because the schools of public health split off from medical schools in the 20th century, and established their own academic fiefdom, and commandeered the name “public health” as their exclusive domain, they ought not commandeer the credit (as Hemenway does here) for inventing and building sewage treatment plants, vaccines, or side airbags. Most of the actual “stuff” that makes public health so effective comes from somewhere else. If there’s to be more funding, give it to the people and enterprises that actually invent and develop that stuff.

Call DrRich a cynic, but he suspects that schools of public health really want more money so they can publish academic papers that will justify – or demand – more invasive governmental action to control private behavior, for the good of the collective. For instance, while DrRich does not know anything about Hemenway himself, he notices that a major interest of his Injury Control Research Center is firearm injury. Nothing wrong with that. But he also notices that the Injury Control Research Center gets a big chunk of its funding from the Joyce Foundation, an organization with a strong, self-professed “anti-gun” (and not merely gun safety, or gun control) agenda. One might be forgiven for wondering whether one of the “public health” agendas of the Injury Control Research Center in this regard might be to help justify stiffer anti-gun legislation. Whatever you may think of stricter gun legislation, diverting healthcare dollars to support one side or the other of a fundamentally political issue does not seem like a good precedent to set.

Let the public health experts get their own funding. Dollars that people pay for health insurance – whether through direct premiums to insurance companies or through tax dollars to Medicare, Medicaid, and whatever else is coming down the pike – ought to go for individual healthcare, and not to any interest group that can assemble an argument that whatever it is they are doing benefits the overall health of the collective. After all, anybody – from gym owners to grocers to game manufacturers to medical bloggers – can do that.

Podcast:

In his previous post, DrRich offered some general issues to consider before one dives into black market healthcare, and reminds his readers why this will not be an endeavor for the faint-hearted. In this post, we will get into some specifics.

DrRich must first assure his readers (and any government officials who may inadvertently stumble upon this blog) that he is a law-abiding citizen, and does not condone illegal activities. So he will suggest here only activities for black market healthcare which, strictly speaking, will not be illegal under American law; though not so much by complying with the law, but by avoiding it.

DrRich trusts that his readers can think up the more illegal kinds of black market activities for themselves, and thus they do not need his help with this aspect of the endeavor. Many of these more obvious illegal forms of black market healthcare (e.g., “medical speakeasies,” located in back alleys for the proletariat, and in swanky office buildings for public officials; rolling surgical suites hidden in semi-trucks; smuggling rings for drugs and medical equipment; an “underground-railroad-style” transport system for itinerant physicians who need to ply their illicit trade while on the move; etc.), can be established by individuals, or by relatively small groups of entrepreneurs, and with relatively little up-front capital or lead time – and with no coaching from DrRich.

But the varieties of black market healthcare which DrRich has in mind – certain “less illegal” activities, which will drive the U.S government into states of apoplexy but over which it will have little legal jurisdiction – will require a much larger scale, and a significant investment in time and energy.  So anyone who is interested ought to get started with the necessary organizational activities right away.

DrRich has three such suggestions. With all three of them, DrRich envisions that implementation would be driven by a major private healthcare organization (or a consortium of them) which has a record of innovative thinking, as well as access to significant financial resources through their own holdings, or through their connections with rich benefactors from around the world. He is thinking of organizations like the Cleveland Clinic, the Mayo Clinic, or the Kaiser system.

For the sake of mankind, DrRich offers these suggestions free and clear. They may be taken up, with his blessings, by any institution or organization that wishes to employ them, with no obligations or strings attached whatsoever.

1) Floating Off-Shore Medical Centers. In this scenario, the Cleveland Clinic (say), with the help of their friends in Abu Dhabi, buys or leases a mothballed former Soviet aircraft carrier (nuclear power preferred), and refurbishes it into a floating, world-class medical center. The ship will ply the international waters off the American coasts, providing regular helicopter transport to and from major cities. There’s a lot you could do with an aircraft carrier, of course, to make it an attractive destination aside from medical care, including (for instance) establishing a world class hotel, food services, casinos and other entertainments. But the chief attraction would be that Americans will be able to buy the best healthcare services in the world, without fear of being arrested.

The fact that this floating medical center will be based on a former warship may turn out to be an advantage. Obviously, it would be useful to maintain at least some weaponry on board, if only to repel “pirates” But given the anger this ship will generate among American government officials, the Cleveland Clinic (or whoever) might be wise to remain intentionally ambiguous about just how much firepower the ship has retained. Just sayin’.

2) Native American Medical Centers. There are two things about the current state of Native American culture which make this approach to black market healthcare at least feasible, if not compelling. First is the recognized “sovereign status” of Native American reservations, the same status which has allowed various tribes across the land to open gambling casinos, even in states which otherwise do not allow such establishments. If their sovereign status justifies casinos (establishments of mere entertainment, which, in fact, encourage bad behaviors of all sorts such as alcoholism, prostitution, smoking and – gasp!- obesity), then surely the same sovereign status would justify establishing advanced institutions of healing.

Second is the deep guilt that Americans rightly feel about the treatment Native Americans have suffered over the years, much of which was arranged by the U.S. government. Note, in particular, that one of the ongoing claims which Native Americans have against the larger American culture is the chronically substandard state of the healthcare services they are provided. So, who will dare stand in the way of these oppressed peoples, when they propose to dedicate a portion of their pitiful remaining sovereign lands (with the help of, perhaps, the Mayo Clinic and its benefactors) to the development of world-class medical centers?

One advantage of the “Native American Strategy” for black market healthcare is that it would allow medical centers of various sizes and emphasis to be established in numerous convenient tribal locations around the U.S., as the need and logistics allow. Within a decade or two, if they play their cards right, Native American tribes may even find themselves controlling nearly 20% of the American economy – which would be justice at its finest.

3) Medical Centers Across the Mexican Border. There are several potential benefits to this suggestion. Converting Tijuana, Nogales, Laredo and Juarez from hotbeds of human and drug smuggling into hotbeds of illicit healthcare would probably be a boon to the local populations on both sides of the border. It would create tens of thousands of good jobs in Mexico, for Mexicans. The heavily-armed gangs of Mexican drug-runners along the border could be hired by the Cleveland Clinic Juarez, or the Mayo Clinic Nogales, as security guards, thus absorbing their “talents” into a more legitimate economy. (Being located so close to the border of a powerful nation which will badly want to terminate these medical centers would, one must understand, create a certain need for security.)

If nothing else, world-class medical centers just across the Mexican border would reverse the flow of illicit border crossings. Americans (and Canadians, who, bless them, would now have to travel much farther south for their healthcare) would suddenly be streaming across desert border crossings into Mexico in the dark of night – and Mexicans would be staying put. And its desperate need to get rid of black market healthcare would, at long last, give the U.S. government a compelling reason to control the borders once and for all. We would suddenly see American troops all along the Mexican border, supported by such features as a “no-man’s land” seeded with land mines, and constant surveillance by drone aircraft armed with cluster bombs.

And before long, Californians wanting to go to the Kaiser Tijuana Medical Center would have to get there by way of Cuba.

Podcast:

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Part 1 of Limiting Individual Prerogatives

Part 2 of Limiting Individual Prerogatives

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The thing about Progressives is that the characteristic which makes them most endearing (and, which makes them most attractive to the unaware), is the very characteristic which makes them the most dangerous.

Fundamentally, Progressives believe in the perfectibility of mankind, or at least, of society. Indeed, they have discovered the very Program which will lead to the perfect society, a society which will maximize the good of the whole. Their vision is so compelling, and their ends so utterly and undeniably right, that it becomes legitimate for them to engage in whatever means are necessary to achieve it. (Indeed, for those who have been paying attention, “By Whatever Means Necessary” appears to have supplanted “Hope and Change” as the catchphrase of our current political leaders.)

The thing that always trips up Progressives (and their more revolutionary cousins, the Communists), is, of course, human nature. In order for their Program to work, it is necessary for each individual to behave in the prescribed fashion. And, at the end of the day, a substantial proportion of the population (any population) will insist on striving for their own individual benefit, rather than (as the Program requires) for the benefit of the collective.

The major competing system of societal organization – capitalism – recognizes this facet of human nature (i.e., the essential imperfectability of mankind, as manifested by the non-suppressibility of self-interest), and attempts to channel it into relatively productive and non-destructive (but still competitive and individually-directed) behaviors that limit the damage, and maximize the public good to a reasonable degree.

In contrast, Progressives attempt to change human nature to fit their inherently superior Program.

The fact that you cannot change human nature to fit the Program is what makes them dangerous. Their initial wide-eyed optimism that us folks will just “get it,” once they explain it to us, invariably evolves to an essential contempt for our limited intellectual capacity. This contempt justifies all manner of prevarications, to fool us into going along. Even in societies where the tyranny of correct-thinking has gone so far as to elicit the cooperation of the people at the point of a gun (rather than through the preferred methods of “education” or misdirection), the achievement of the predicted perfect society is invariably prevented by the recalcitrance of human nature. (The final realization that not even an all-powerful central authority can make people behave in the prescribed way always produces a nearly psychotic frustration that – in virtually every Communist country – has led to atrocities against various subsets of the recalcitrant people.)

DrRich does not believe there will ever be pogroms in the United States.

But this does not mean that the Progressives will always be kind and gentle as they attempt to achieve their goals. As DrRich sees it, in the U.S. the Progressives have clearly evolved to the “contempt for the masses” phase of their Program, a phase which justifies all manner of techniques – just this side of violence – to get us all to cooperate. Currently they are intent on demonizing their opponents as being racist, stupid, uneducated, selfish, overly dependent on outmoded supernatural beings, violent, and (of course) obese. This demonization is quite useful, since there is obviously no need to address any actual ideas put forth by such as these, even if they were capable of the feat of “ideas.”

Healthcare is, at present, the chief battleground in the war between Progressives vs. non-Progressives in the U.S., and the outcome of this battle will likely determine the success or failure of the entire Progressive Program. And the most fundamental (and emblematic) aspect of this battle is over what to do about the “doctor-patient relationship.”

The classic doctor-patient relationship was a celebration of the primacy of individual rights. And, for over 2000 years (at least since the advent of the Hippocratic Oath) guaranteeing the sanctity of that relationship was the basis of all medical ethics.

Until very recently doctors, patients, philosophers and ethicists recognized that, when you are sick, you are no more capable of navigating a complex and hostile healthcare system than are accused felons a complex and hostile legal system, and you are no less in peril if you run afoul of that system. And, just as the felon has a right to a personal advocate, a professional whose job is to protect his individual interests against the conflicting aims of the “system,” so does the patient. That is (quaint conventional wisdom held), when you are sick, you should be entitled to at least the same protections as when you rob a convenience store. And the doctor-patient relationship was supposed to guarantee you that right.

This is why, throughout the ages, the basic precepts of medical ethics were aimed at guaranteeing the sanctity of the doctor-patient relationship. Fundamentally, these ethical precepts required the physician to place the needs of his or her individual patient above all other considerations.

It should be clear to everyone that, under either our “old” healthcare system or the one that Obamacare promises us, this formulation of the doctor-patient relationship cannot be allowed to stand. Neither the insurance executives nor government officials can allow spending decisions – that is, decisions on how to spend their money – to be made by individual patients (and their personal advocates). For this reason, the classic doctor-patient relationship had to go.

And so, in 2002, official medical ethics was formally amended to require physicians (while still giving lip service to their obligation to individual patients) to strive for a “just distribution of healthcare resources.” That is, official medical ethics now makes it ethical for physicians to ration healthcare, covertly, at the bedside – and indeed, makes it unethical for them to fail to do so.

The New Ethics has been enthusiastically supported by medical ethicists worldwide (a field which now seems to be dominated by utilitarians), and worse, has been embraced by all the world’s major medical professional organizations. DrRich has not embraced the New Ethics (on the grounds that it places individual patients at great peril, and destroys the profession of medicine), and neither have many (possibly a majority) of older physicians. But it has been taught in medical schools around the world for over a decade, and in another decade it is likely that the vast majority of practicing physicians will accept as a matter of course that their primary obligation is to control healthcare costs, and only secondarily to try to meet the needs of their individual patients.

The plan, therefore, is for Obamacare to provide physicians with directives from expert panels on which medical services to supply to which patients and when, and for the New Ethics to allow physicians who go along with such directives to live with themselves. The feasibility of this plan depends entirely on physicians acceding to the program.

So, incentives are being put in place to “help” doctors cooperate. Quality measures will be implemented, with “quality” being defined as doctors doing what they’re told, and reimbursement will be tied to one’s quality rating. Possibly more persuasive will be the fact that the Feds can construe the failure to follow handed-down rules, regulations and guidelines, at any time, as a federal crime. (Even doctors who don’t mind being labeled as “substandard quality” – perhaps even considering the label as a badge of honor – will mind going to jail.)

But by whatever means necessary, the happiness of the government is to be the doctor’s first consideration, and not the happiness of their individual patients. The classic doctor-patient relationship is being terminated with extreme prejudice.

To see just how important it is to destroy the doctor-patient relationship, one merely has to observe what is happening to primary care doctors who have the audacity to leave the system, and set up a direct-pay medical practice.

Part of the problem, to be sure, was caused by these doctors themselves. The first few to do so unabashedly catered to rich patients, and to attract the rich, referred to themselves as “concierge” practitioners. This name (and its elitist connotations) have been forcibly affixed to all direct-pay practitioners, even as this style of practice has evolved into a much more democratic form. Today, more and more doctors are starting direct-pay practices (in which patients pay the doctors out of their own pockets) which are easily affordable to anyone who can afford a cell phone or cable TV contract.

While many direct-pay practices offer patients certain benefits they can usually not get from primary care doctors who remain in the approved system (such as phone and e-mail access, same-day appointments, appointments lasting as long as necessary instead of the allotted 7.5 minutes, etc.), the fundamental benefit, to both the patient and the doctor, is that it restores the classic doctor-patient relationship. The physician’s primary obligation is no longer to the 3rd-party overlord, or to the Progressive ideal of social justice, but to the patient.

And while critics (who abound) attack direct-pay practitioners for their elitism, laziness, and greed, their real issue is that direct-pay practitioners are acting as if their primary duty is to their individual patients, and not to the needs of society. This latter fault simply cannot be tolerated.

Having gained nearly complete control over the behavior of primary care practitioners, it is critical for Progressives – in making sure that practice by handed-down “guidelines” is not simply the only legal way to practice, but also the only ethical way to practice – to shut the door to any alternative forms of primary care. Direct-pay practitioners are a menace because they threaten to raise the expectations of both doctors and patients. Perhaps, doctors and patients might tell themselves, there really is a way to maintain individual autonomy within the healthcare system.

The attacks on direct-pay practitioners have followed the usual scheme Progressives follow when they discover a faction they need to suppress. First, they were ridiculed. “For a Retainer, Lavish Care by ‘Boutique Doctors,’” said a headline in the New York Times in 2005. Then, they were demonized, widely attacked for their elitism, laziness, greed, and lack of fundamental medical ethics. In this latter effort, it was not difficult to find fellow physicians – generally, from the medical organizations which promulgated the New Ethics – to lead the attacks. There are countless examples. DrRich will give just two.

Anthony DeMaria, then President of the American College of Cardiology, criticized the practice of direct-pay medicine in an article in the JACC in 2005, saying, “Personally, I do not mind if people acquire yachts or personal trainers if they have enough money, nor would I object if they secured a physician at their beck and call. However, unlike yachts, health care is not discretionary, and everyone should be entitled to the same quality.” As a matter of social justice, direct-pay physicians improve healthcare quality for only some patients, and so have no place in the healthcare system.

In an article in the New England Journal of Medicine, Troyen A. Brennan (M.D., J.D., and M.P.H., so we know we’re in trouble) really gets to the point. Referring to direct-pay practices as “luxury primary care,” he notes that “traditional medical ethics is rather poorly equipped to address issues related to luxury primary care.” That is, while “traditional” medical ethics always places the individual patient first, that kind of thinking is now outmoded. “(M)ost ethicists now agree that the financial structure of health care is an important subject for ethical consideration. Access to health care, in particular, is a salient ethical issue.” Direct-pay practitioners threaten (by their elitism and the limited size of their practices), to limit access to primary care, and thus are in fundamental violation of medical ethics.

The argument here, for those who missed it (advanced by fellow physicians no less), is that, of the two competing ethical precepts now established by New Medical Ethics (i.e., the physician’s obligation to the individual patient vs. the physician’s obligation to society), clear primacy is to be given to the physician’s obligation to society. Physicians must (like it or not) participate in covert bedside healthcare rationing. Physicians who take the only path remaining to them that allows them to make the individual patient their primary obligation are to be castigated as ethically deficient.

When ridicule and demonization fail to suppress their opposition, Progressive dogma indicates it’s time to resort to force. The first pass in this regard, of course, is always to render the opposition illegal. (Actual violence is reserved for criminals who persist in their misbehavior, despite more polite efforts to get them to behave lawfully.)

Making direct-pay medical practice illegal has not been accomplished yet, but clear efforts have been made in this regard. Noting with alarm the rise of direct-pay primary care, numerous Congresspersons have issued statements of concern, suggesting that perhaps Congress should look into the propriety of such activities.

Indeed, the first step by Congress has already been taken. In 2003, as part of the Medicare Prescription Drug, Improvement, and Modernization Act, Congress directed the GAO to study and report on the effect of direct-pay practices on Medicare patients. The GAO did so in 2005, and a fair paraphrase of its report is as follows: “The practice of direct-pay medicine is not currently a threat to Medicare patients, because the direct-pay movement is not large enough yet to have an impact. If it does begin to have an impact on Medicare patients, action will have to be taken.” That is, direct-pay medicine was considered OK in 2005 not because it was inherently an ethical and legal form of medical practice, but simply because there were not enough practitioners at that time to significantly affect Medicare patients. The clear implication is that Congress stands ready to pass laws outlawing – or, at least, severely limiting – direct-pay practices, as soon as those practices begin to “impact” the system.

Certain state governments are not waiting for Congress to ban direct-pay practices. The state of Maryland (and a few others) have taken the creative position that, because many direct-pay practices work on a retainer basis, they meet the definition of a health insurance company. And as a health insurance company, to be considered legal entities, they have to have millions of dollars set aside to pay for unforeseen “claims.” (Interestingly, this same argument was not applied to Maryland lawyers, who also often work on a retainer model.) According to the Baltimore Sun, the state’s stance in this regard has already successfully caused several primary care physicians to abandon their plans to become retainer practitioners.

Less devious (but more draconian) than the state of Maryland is the state of Massachusetts (whose universal healthcare system, we’ve all heard, is a preview of Obamacare circa 2015). A bill is under consideration in the Massachusetts Senate (Bill 2170) which requires doctors, as a condition of their licensure, to accept payment rates as determined by the government. If it passes, it will be the first actual legislation in the U.S. to ban direct-pay medicine, if only by making it completely impracticable. (Thanks to Dr. Wes for pointing out this important development.)

Since medical licensing is controlled by the various states, of course, it would take 50 bills like the one in Massachusetts to really get rid of direct-pay healthcare. But there are other ways for the Feds to accomplish the same thing. Now that the federal government directly controls all student loans, for instance, it would be a simple matter to make those loans contingent on agreeing to become primary care doctors working strictly within the government controlled system, or to offer loan forgiveness for doctors who agree to do so, or to rescind favorable re-payment conditions (retroactively, and decades after the fact, if necessary) for doctors who go to a direct-pay model later in life.

DrRich does not really know how the Progressives will actually place the final nail in the coffin of the doctor-patient relationship. All he knows is that they have – well, more than the desire – the deep and abiding need to kill that relationship, once and for all. Unless we the people decide we ought to stop them, this is going to happen.

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Part 4 of Limiting Individual Prerogatives

In what has quickly become a bad habit, DrRich once again provides a misleading title. Obviously, there’s plenty of waste and inefficiency in our healthcare system, enough to suit almost any taste, and DrRich deplores every bit of it.

Indeed, DrRich strongly suspects that at least 20 to 30% of all healthcare spending is completely wasted, and has seen claims (masquerading as proof) that the actual value is as high as 50%. So again, despite the title of this post, no matter how you look at it there is plenty of waste and inefficiency to go around.

It’s just that there’s not, well, enough.

Before you go away mad, let DrRich quickly explain (quickly, at least, for DrRich) what he means here. Healthcare reform is in the air, and we all know that any effective healthcare reform is going to have to find a way to control healthcare spending. And a central assumption of any reform plan yet proposed is that we can control spending by eliminating – or at least substantially reducing – the vast amount of waste and inefficiency in the healthcare system. Some propose to do this by incorporating the efficiencies of the marketplace (though these individuals have now been run out of town and won’t be bothering us anymore), some by adopting and enforcing stricter regulations, others by introducing a single payer healthcare system, and still others by mandating new technologies such as electronic medical records. But one way or another, each scheme for reforming healthcare proposes to bring spending under control by reducing waste and inefficiency.

Another way of describing what the reformers are telling us is: There is so much waste in the system that we can avoid healthcare rationing by getting rid of it. Most Americans believe this. Most policy experts believe this. DrRich suspects that even most of his loyal readers believe this, despite what he’s been telling you all this time.

But this is unfortunately false. No matter how much waste and inefficiency you think might be plaguing our healthcare system today, there’s not enough to explain the uncontrolled rise in healthcare spending we have been seeing for decades, and therefore, not enough to allow us to avoid rationing altogether.

And in this sense, there is not “enough” waste and inefficiency in healthcare.

DrRich has tried to explain this before, but he will now try to do it better, because it’s important. He will do it using one of the three universal languages, the language of Math (the other two being the language of Love and the language of Healthcare Rationing, both of which are encumbered by expressions of impassioned pledges, heartfelt exaggerations, and other blandishments, and are thus unsuited to a sober discussion of unpleasant truths).

But first, there is an underlying concept we must agree upon, a concept our political leaders are loath to address. To wit: The real fiscal problem with our healthcare system is not simply that we’re spending a lot of money on healthcare, or even that we’re spending a large proportion of our GDP on healthcare. Surely, if we simply had to live with continuing to spend 15% of our GDP on healthcare, we could figure out a way to do that. But that’s not really the problem. The real problem is that healthcare expenditures are growing at a double digit rate of inflation, several multiples faster than the overall inflation rate, such that, over time, an ever larger proportion of our annual GDP is being consumed by healthcare expenditures. Unless this disproportionate rate of growth is stopped, eventually healthcare spending will consume our entire economy. (Rather, what will actually happen is that it will grow to the point of producing societal upheaval, sending us back to a more typical era for mankind, where healthcare is a little-thought-of luxury, and not a necessity or a right. This will happen well before healthcare consumes 100% of the economy.)

To reiterate, it’s not the amount of spending on healthcare that is creating a fiscal crisis, it’s the rate of growth of that spending.

There are only two things that can possibly account for this excessive inflation in healthcare expenditures. Either it is caused by unrelenting growth in wasteful spending (as we are assured by our political leaders), or it is caused by unrelenting growth in useful healthcare spending. If it is the latter, then in order to get spending under control we must ration. So therefore (we all fervently pray), the rate of growth must be caused by wasted spending.

This desired conclusion, unfortunately, leads to mathematical absurdities, and therefore (for anyone who eschews magical thinking) turns out to be utterly false.

DrRich is going to show you data from a spreadsheet. It illustrates what would have to happen in order for wasteful spending to account for our current healthcare inflation. The spreadsheet is based on the following four assumptions:

Assumption 1) The proportion of healthcare spending today that is wasteful is taken as 25%. The actual number, of course, is not possible to discern with any real confidence. It depends, for one thing, on who gets to define “wasteful.” If I’m a 92-year-old man who gets a $12,000 stent procedure to eliminate my angina, I and my doctor might consider it money well-spent, while you might consider it wasteful. DrRich has arbitrarily chosen a number that falls within the range of popular estimates. But it’s a spreadsheet. If you don’t like 25%, substitute your own estimate. You will find that the rate of wasteful spending we assume for Year 1 in this spreadsheet has little effect on the outcome.

Assumption 2) The annual overall rate of growth of healthcare spending (i.e., healthcare inflation) is 10%.

Assumption 3) The annual growth rate of useful (i.e., not wasted) healthcare spending is economically well-behaved. That is, it matches the rate of overall inflation. The spreadsheet therefore assumes a 3% annual inflation rate for useful healthcare spending. (DrRich begs his readers to notice that this assumption is the one implicitly invoked whenever anyone says that all we need to do in order to control healthcare costs is to eliminate waste and inefficiency. In effect, our spreadsheet is designed to test the logic of this assumption. This assumption must be true if we are to to avoid healthcare rationing, because if useful healthcare spending were not economically well-behaved, then no matter what the rate of growth for wasted healthcare spending, we would still have disproportionate healthcare inflation – and rationing would be unavoidable.)

Assumption 4) The difference between the “well-behaved” growth of useful healthcare spending and the overall rate of healthcare inflation is accounted for by spending on waste and inefficiency. This of course, is the assumption that underlies all proposals for healthcare reform.

(Note: If you would like to play with the actual spreadsheet itself, e-mail DrRich and he’ll send it to you: DrRich at covertrationingblog dot com)

Year	Index of overall Dollars Spent per year	% wasteful spending	% of annual increase due to useful spending	% of annual increase due to wasteful spending
1	100	25%	-	-
5	146	42%	18%	82%
10	236	59%	13%	87%
20	612	78%	7%	93%

We see from this table several things. First, as expected, the amount of money we’re spending on healthcare, assuming a rate of healthcare inflation of 10%, is doubling roughly every 8-9 years, a growth rate that is ultimately unsupportable.

Second, in order to account for this unsupportable growth in healthcare spending by invoking waste and inefficiency, the proportion of healthcare spending that is caused by waste must increase to ridiculous proportions very rapidly, such that (for instance) by the 10th year we will have more than doubled (59%) the proportion of all healthcare expenditures that are wasteful; and by the 20th year, nearly 80% must be wasteful. Similarly, the proportion of the annual increases in healthcare spending that would have to be due to waste and inefficiency rapidly climbs to equally ridiculous proportions. By year 5, wasteful spending will have to account for 82% of the annual increase in healthcare expenditures, and that proportion continues to climb, eventually approaching 100%.

To DrRich, these numbers seem absurd on their face. But if you still need to be convinced, consider that in real life, runaway healthcare inflation has already been taking place for decades – so our position on such a spreadsheet would not be at year 1, but at year 20 (or higher). And no matter what value for wasteful spending we might have plugged in at year 1, by year 20 wasteful spending would have to be well above 80%, and more likely approaching 100%. In order for waste and inefficiency to account for the situation in which the American healthcare system finds itself today, therefore, one would have to believe that virtually all healthcare spending is wasteful. (And if you believe that, then what does it matter that tens of millions can’t afford healthcare?)

Now let us illustrate the same point in a slightly different way. This time, let’s assume that as recently as 2006, our healthcare system was 100% efficient. That is, only three years ago there was no waste whatsoever. Then let’s allow that the remaining three assumptions given above are still operative. The following table results:

Year	Index of overall Dollars Spent per year	% wasteful spending	% of annual increase due to useful spending	% of annual increase due to wasteful spending
2006	100	0%	100%	0%
2007	110	7%	30%	70%
2008	121	15%	28%	72%
2009	133	17%	26%	74%

We can see from these results that, even if only three years ago we had a completely efficient healthcare system, in order for waste to account for the excess growth in healthcare spending we’ve experienced since that time, then as much as 74% of today’s annual increase in spending has to be due to waste and inefficiency. Indeed, unless at some point within the second term of George W. Bush we actually had a completely efficient healthcare system (which seems doubtful), this spreadsheet tells us (again) either that our fervently held belief that waste and inefficiency accounts for healthcare inflation is completely wrong, or that today virtually all of our annual increase in healthcare spending must be due to waste and inefficiency, and none due to useful healthcare.

Play with the spreadsheet yourself. You will quickly see that as long as we insist that wasteful spending must account for the unsustainable growth we’re seeing in healthcare costs, then whatever our assumptions may be regarding the current proportion of wasteful healthcare spending – whether we say it’s 20% or 50% or 0% – we very quickly encounter the same mathematical absurdities.

One can only surmise from this analysis (done, DrRich reminds you, with actual Math) that our desired conclusion is wrong. A substantial proportion of our growing healthcare expenditures must necessarily be coming from real, honest-to-goodness, useful healthcare. And if we’re going to substantially curtail that growth, we’re going to have to curtail useful spending. Which means we have to ration.

But, once again, we’re Americans and Americans don’t ration. Which is why we’ve commissioned the big insurers and the government to do the rationing covertly, a task they have accepted with great gusto. DrRich is compelled to point out, once again, that waste and inefficiency is the sine qua non of covert rationing. Disguising all the rationing activity as something other than rationing fundamentally requires opaque procedures, unnecessary complexity, bizarre incentives, Byzantine regulations arbitrarily and variably enforced or ignored, and the diversion of healthcare dollars to non-healthcare ends (such as corporate profits, expanding layers of government bureaucracies, and other massive bureaucracies within the healthcare system created to defend against government bureaucracies). Covert rationing multiplies waste and inefficiency, and does so systematically. To reduce the necessary rationing to the smallest amount possible, we will have to figure out a way to do the rationing openly, and not covertly.

In the meantime, DrRich does not kid himself that exposing the mathematical absurdity of the chief assumption espoused by our political leaders, in their brave efforts to reform healthcare, will change hearts and minds. American political partisans, not to mention the American media, eat mathematical absurdities for lunch. And magical thinking amongst the populace, at least when it comes to the exuberant accumulation of household (and national) debt and the application of medical science, far from being discouraged, is actively promoted.