Monday, November 21, 2016

Call to Action: Organizing for Patient Care

By NIRAN S. AL-AGBA, MD and MARGALIT GUR-ARIE     

On November 8th America elected a President who ran on a promise to restore government of the people, by the people, for the people (among other things). However, we cannot expect such government to be given to us on a silver platter, no matter who resides in the White House. We must build it ourselves, by definition. Government of, by, and for the people requires the people to stand up and do more than just vote every four years, do more than author clever blogs, do more than compose brilliant tweets, post cynical quips or write constructive comments on the websites of power. Self-government requires informed citizens with a vision to organize, mobilize, and take purposeful action.
For the last eight years we engaged in all of the former and none of the latter. We know many of you are in the same predicament. We are the everyday people and frontline doctors everybody in government is supposedly trying to help. We don’t entirely doubt the intent, but the end results have been so much less than we want, so much less than the American people deserve, so much less than we know is possible. We come from vastly different backgrounds. We have diametrically opposed political ideologies. We have a broad and dynamic spectrum of prescriptions for how health care in America should work. This is our strength.

You may be elated by the 2016 election outcome; you may be on the fence, indifferent, worried, depressed or positively enraged. Whether you love it or hate it, you cannot deny that something extraordinary happened on November 8th. Whether you think disaster breeds opportunity or victory itself is the opportunity, let’s “seize the present; trust tomorrow even as little as you may” and try to gain some control over our personal and professional fates.

Call to Action

We would like to propose that we organize a workgroup of physicians and people with interest in health care to create evidence and consensus based guidance and recommendations for the new administration as it undertakes major changes in health care policy, legislation and regulation. Our initial thoughts are that we create an objective position paper to address the impeding changes to current health care legislation, free of political and partisan shenanigans. Our dreams are that this grows into a perpetual grassroots advisory group which brings real-world experiences, varied points of view and wisdom from the frontlines of medicine and from everyday life into the hallowed halls of government to inform the work of public servants.

If you think the American people and their doctors should have a voice in governance, if you believe the welfare of your patients stands above politicking, if you want to amplify your voice and the voice of others, please join us. If you think you can contribute a small amount of time to such effort, we invite you to kick start this endeavor. You can remain anonymous if you so choose. You can contribute as much time as you have available. You can choose how, when and what. Let’s leave the actual details open and brainstorm together how best to move forward quickly.

Let’s Roll

Are you all in? Would you prefer to dip your toes in the water first?
Email us today: mga111026 at gmail.com
We will communicate via email to set up a conference call and take it from there. We will do the housekeeping, bottle washing and ashtray emptying to get us started. For those who already expressed enthusiasm (or guarded interest) on Twitter and elsewhere, retweet, spread the word and let’s make this happen. It’s time.

Download PDF version. Please share freely.



Saturday, November 12, 2016

Is the Better Way Really Better?

Dear President-elect Trump,

The American people, myself proudly included, chose to send you to Washington DC to do their bidding. That’s what happened on November 8th 2016. Everything you hear now from the elite punditry is aimed at obfuscating this simple truth. Forget about dainty glass ceilings, we the people were able to break through the fortified ramparts erected by entrenched money and power and exercise our right to govern ourselves. I would caution the smug intelligentsia against underestimating the wisdom of the people once again, and I would caution you against forgetting who sent you there and why we did so. We now know we have the power, and what the people giveth, the people can taketh away.

RyanCare

The ecstatic welcome you received from Paul Ryan and Mitch McConnell the other day looks more like an act of violence than one of true reconciliation. Fair weather friends are usually there because they want something, and in this case they want to hijack the people’s agenda and replace it with their own conservative garbage. Mr. Ryan in particular has been proposing bogus alternatives to Obamacare with alarming regularity. Similar to Obamacare, Mr. Ryan’s health reform plan is based on belief in his own superior intelligence and devoid of any evidence that it can indeed work. Unlike Obamacare, the Ryan plan is also based on the assumption that helping the poor get poorer and the rich get richer is the ultimate role of government.

A few days before this historic election, I used your Old Post Office renovation project to highlight the big picture facets of health care in America in ways you can easily relate to. It will be very helpful if you read that first, believe me. From reading your latest Obamacare repeal and replace literature, I am starting to think that you are about to swallow Mr. Ryan’s fantasy hook, line and sinker. I would like to remind you that on the campaign trail you promised to replace Obamacare with “something terrific”. In keeping with tradition, the GOP Better Way may be great for GOP corporate donors, but for us, it is anything but terrific.

Have you read Mr. Ryan’s plan, Mr. President-elect? I suggest you do, and I suggest you ask your old friend Chuck Schumer to bridge an introduction to Bernie Sanders, who is perhaps the only other elected public servant not beholden to lobbyists and special interests. If I had to summarize the difference between RyanCare and Obamacare I would say that whereas Obamacare is providing people with a government defined set of health care benefits, RyanCare is proposing to make a government defined financial contribution towards purchase of health insurance. This difference extends to all insurance including Medicaid and Medicare, with RyanCare essentially dismantling Lyndon Johnson’s 1965 landmark legislation. I know you’re now in the “take the lumps out, son” phase, but some lumps were just meant to be taken as is.

Industrial Care

While Obamacare and RyanCare differ on how they finance health care services, they are unsurprisingly similar when it comes to controlling health care delivery costs, because this portion of both nightmares was dictated by corporate lobbyists and special interests. When you leave medical decisions in the hands of millions of people interacting with hundreds of thousands of doctors in unique ways, the result is utter chaos, or what we call freedom. The Obamacare lieutenants decided early on that the best way to exert control over costs is to industrialize health care.  You have to admit that this sounds pretty tempting. Industrialization has made lots of things cheaper and often better and more reliable. The conservative Ryan plan, which is by definition dismissive of workers and non-wealthy people in general, went all in with this aspect of Obamacare.

But here we are attempting to industrialize people. Not only is this impossible without enslaving humanity as a whole, but these futile attempts at industrialization are costing us a fortune. This is the fundamental round-hole-square-peg paradigm plaguing both Obamacare and RyanCare, because insurance prices are driven by the prices of goods that are being insured and you cannot have affordable insurance prices for unaffordable products. During the 2008 election season, President Obama made fun of Mrs. Clinton’s proposal to mandate that everybody buys health insurance, because it would be like trying to solve homelessness by mandating that all homeless people buy a house. A couple of years later he did precisely that. RyanCare on the other hand is turning health care into a food stamps program.

Here is the most important piece of health care information you’ll ever need: When you go to a doctor who runs his or her own small business, you pay half as much as when you go to a doctor that is employed by a large health conglomerate, and you get better care to boot.

To be fair, consolidation of health care started decades before Obamacare, but the Obama administration trifecta (the 2009 Stimulus, the 2010 Obamacare and the 2015 MACRA) made consolidation of health care providers pretty much mandatory. In a perverse and illogical way, this set of laws ensures that excessive health care prices are baked into this cake in perpetuity. In particular, the bi-partisan and fairly new MACRA legislation represents a complete regulatory capture of medicine, its transition to indentured servitude to moneyed interests, and hundreds of billions of health care dollars wasted.  Get rid of MACRA Mr. President-elect. Replace it with what Sen. Tom Cotton suggested on the floor right before the Senate voted on it. You do that and you are 90% where we need you to be.

The other day I listened to your favorite negotiator, Mr. Carl Icahn, and his description of how excessive regulations are killing our industries by discouraging capital investment in new machines, which in turn suppresses productivity growth, leaving stock buybacks the only venue for CEO enrichment. Health care is different. In health care, regulatory capture mandates the purchase and expensive operation of machinery that is designed to kill productivity, which leaves consolidation to gain market power, the only revenue enhancing alternative. MACRA is the final, and still removable, nail in this coffin. Whatever you do with Obamacare, if you leave MACRA in place and allow the passage of the 100% lobbyist crafted 21st Century Cures Act, it will all be for naught. To put it in construction terms, if your remodeled Obamacare is the building, MACRA and the Cures Act, are the termites and black mold devouring it from within.

Words that Go Bump in the Swamp

I know the President of the United States sets the tone, but cannot possibly be delving into policy details. Unfortunately, Mr. President-elect, policy details is where corruption lives. You may not be bound by allegiances to money and power, but your political appointees will be. Big league. They will come to you with executive summaries, both written and verbal, so here are three of the most common, most potent and most dishonest health care buzzwords. You should never use them, and you should never use advice from any swamp dweller that is using them, because these are code words for defrauding the public and we, the public, know that, and we are watching carefully. As simple as that.

Patient-Centered – Every calamity in health care is patient-centered. Every time you hear or read patient-centered, repeal and replace it with “circular firing squad”. The most common usage is to demand “transformation to a patient-centered model of care”. Now, you’re a smart man, think. What the hell does that mean? Try these: guest-centered resort, golfer-centered club, gambler-centered casino. See what I mean? People who pitch patient-centered ideas are known as “thought leaders” or “industry experts” and are invariably looking to fleece either doctors or taxpayers or both.

Patient-centered means big health systems using big computers to collect and analyze personal information of patients and target them for certain services that optimize payments and revenues for the system. Very much like the RNC campaign software worked to target voters for you. You think that system was voter-centered? With that answer in mind, perhaps it would be a good idea to remove that patient-centered reference from your website and fire whoever put it there. You are supposed to be the authentic one, remember?

Value-Based – This is a very simple one to understand, because as a businessman, you should know what value-based pricing means, and you should know that it is not something that has the buyer’s welfare in mind. You should also be cognizant of the fact that value-based schemes are intended to enable wealthy patrons to purchase better stuff, while the masses are kept content with generic, cheap stuff. This may work well for socks, but this is not how health care can or should operate. There is no such thing as generic versions of coronary bypass surgery, or buy-one-get-one-free dollar-store stents.

Value-based care is the key to the regulatory capture of medicine. Its sole purpose is to herd doctors and the working class into cheap, substandard systems of health care, and use the leftover money to enrich a vast array of special interests, ranging from insurance companies, think tanks, Silicon Valley vultures, and all the way to software developers in India and computer manufacturers in China. Like all fraudulent schemes to steal hundreds of billions of dollars, this is a huge and very complex subject, but for now you just need to beware people carrying value-based health care solutions. Treat them like they were carrying the plague.

Transparency – I heard you read this term from the teleprompter in a speech about health care. I know you didn’t put it there. Please, stop. President Obama promised the nation that his will be the most transparent administration in history. It ended up being the exact opposite. You said many times during your rallies that you are struck by how smart the American people really are. You were correct in that assessment. We may not look smart, or sound smart, but we are smart and you, of all people, should sympathize with our predicament. We know that a promise of transparency is only necessary if the enterprise is a secretive sham. When you promise transparency in health care prices, we know that we are about to be brutally beaten, raped and robbed. Transparently.

Bottom Line

We did not vote for you because we fell in love with the Republican Party elitist agenda. If that were the case we would have elected Mitt Romney in 2012 or Jeb! in 2016. We picked you precisely because we recognized that the conservative agenda, much like the progressive agenda, is an anti-working people agenda. We know what “defined contributions” are. We know what “vouchers” imply. We know what “skin in the game” means for us. And we know what the synonyms for “modernizing” Medicare and “block granting” Medicaid are. Thanks, but no thanks. We didn’t take much of your campaign-trail bluster literally, but we took your promise to be our voice seriously. Consider this a friendly reminder from the deplorable gallery.
Godspeed Mr. President-elect!

Friday, November 4, 2016

Our Deplorable Health Care

Even the most ardent Obamacare supporters are now forced to admit that the law has hit a rough patch this year. The opposition to Obamacare is positively gloating with self-congratulatory “I told you so” assessments of the supposedly dire situation. Defenders of the cause are counteracting with the customary deluge of charts and graphs to prove unequivocally that Obamacare is actually turning out better than they expected. Integrity and honesty being in short supply on both sides of this quandary, chances are excellent that no matter what happens next, the American people will lose big league, unless….

If Mrs. Clinton becomes the next President of the United States, Obamacare will survive largely unharmed with a few minor tweaks to address a few minor initial oversights, best summed up by Sara Rosenbaum, a professor of health law and policy at George Washington University: “The subsidies were not generous enough. The penalties for not getting insurance were not stiff enough. And we don’t have enough young healthy people in the exchanges.”  To complete the solution, Mrs. Clinton may very well throw in an option to buy into a Medicaid managed care plan for rural hillbillies (similar to the Arkansas “innovation”), and call it “the public option” to make the lefty wing of her party happy.

If Mr. Trump becomes the next President of the United States, Obamacare will come under vicious attacks. Mr. Trump, who is running as a Republican, adopted the GOP “repeal and replace” Obamacare battle cry pretty much verbatim.  On Tuesday, one week before the election, at Valley Forge of all places, the Trump team unveiled its alternative to Obamacare. There was not much under that veil: selling insurance across state lines, health savings accounts, price transparency and Medicaid block grants to states, along with a commitment to retain the preexisting conditions clause and to have a transition period so nobody gets hurt. Team Trump didn’t even try to come up with a serious solution and I’m glad they didn’t, because it would have been incredibly dumb if they did, and because this gives me an opportunity to make my case.

                                                                       ~~~~~~~~~~~~~~~~~

Dear (perchance) President Trump,

I know you don’t know much about health care, and that’s okay, why should you? You probably know that health care isn’t working well in America. Very few things seem to be working as well as they should or as well as they used to work. This, after all, is why you say you ran for President. There is unanimous agreement that health care needs to be made great again. The disagreement is on how to go about it. On the campaign trail, you had to come up with something to throw against Obamacare, which is fine, but now you have to actually fix it and those are two very different things, as all Presidents before you discovered to their chagrin, so here are a few Obamacare points to keep in mind.
  • Obamacare cannot be repealed and replaced in one stroke. It’s a lovely catchy phrase, but Obamacare is massive legislation that begot more legislations, such as MACRA (look it up), and thousands of regulations, many already fully implemented, others in various phases of implementation. Money has been spent, mergers and acquisitions have occurred, companies have been funded, contracts have been awarded, people have been hired, and this sea of change is engulfing private and public sectors inside and outside health care to the tune of $3 trillion dollars annually. You cannot change 20% of the economy the first day in office. Not even if you know precisely how you want to change it. And you don’t. My advice here is to settle down for the long haul.
  • Obamacare doesn’t need to be repealed at all. It just needs to be gradually replaced. It’s like renovating the Old Post Office with the tenants living in the building through the entire project. It’s very tricky because the end results are paramount, but the process itself is as important. The tenants, you see, are the American people, and you work for us now, and I assume you don’t want to get fired mid project. We expect you to come in under budget and ahead of schedule, of course, but we also expect no dust or debris in the lobby, no beams crashing on our heads, no interruption in utilities, and very little noise, and you promised not to disappoint us. It’s going to be wicked hard, but we know you can do it, hence our vote.
  • Obamacare is not health care. Obamacare is the two bit façade they slapped on our health care. Fixing health care is precisely like renovating a building. Sure, you have to rip off the cheap paint and plaster, but you don’t start demolishing things like a bat out of hell, do you? First you get engineers to assess the building, its structural integrity, its surroundings and its potential or lack thereof. You get architects to look at blueprints, floor plans, shafts, beams, columns, electric, gas, water, HVAC, etc. You do some market research to see what people want and can afford. Then and only then, you make new plans, you make schedules, you price and choose materials, you bargain and fight, you hire workers, and the fun begins. I’m pretty sure you know what happens if, at any point, you skimp on prep work.
  • Obamacare was put together by political hacks who serve special interests and their lobbyists, and by ideologues who think the American people are too stupid to care for themselves. Obamacare in its totality is a corrupt entitlement system for large health care corporations and for Silicon Valley. If you assemble the conservative version of the Obamacare team of scavengers, your will fail. If you accept the perfidious, back-stabbing, premises of the Ryan plan to gut health care for the people who voted for you, you will fail. If you want to fulfill your promise to the American people, you’ll have to bypass the punditry swamp, put on a hardhat and go down to where health care happens and get your information first hand and free of charge.
Obamacare is irrelevant. Obamacare is at a minimum a distraction and at a maximum an impediment to affordable, high quality health care, because Obamacare misses the point entirely. I am sure you know from personal experience that in America one can get the best health care in the whole world, if one belongs to the privileged elite. What needs to be fixed is the distribution of health care across the nation. Not to disparage your “policy” speech at Valley Forge, but perhaps you should consider that the health care Inferno is nine circles deep, and what you see at first blush is just a hint of the horrors that lay beneath.
  • Health care is too expensive in America because America has become too poor. Health care is too expensive because American workers didn’t get a meaningful pay raise in decades. Health care is too expensive because poor people tend to be sicker and so are their children.  Health care is too expensive because there are too many middlemen and regulators between doctors and patients taking profits for busywork that adds no value. And most of all, health care is too expensive because politicians must pay back for their last campaign, and raise money for the next.
  • Health care is not a “consumer” product or service, and as Bill Clinton said, health insurance is not like auto insurance or home insurance. People don’t want to “shop” for medical care like they shop for hotels or shoes. It is frightening and humiliating to shop for your life or the life of your child. Imagine if you had to do that in a dire situation and understand that all people feel the same way (even the deplorable ones). Price transparency is just a load of crap. It’s one of those empty phrases politicians use to hoodwink voters. You are not a politician, so don’t do it. Just say no.
  • Free market for health care will work as well as free trade is working for the economy as whole. There is no such thing as free trade or free markets. There never has been and never will be. Trade and markets are manipulated and defined by the shrewdest and strongest participants. Sick people of limited means are no match for global corporations that managed to bring our entire government to its knees. Free market health care will leave most Americans with no doctors, no medicine and no care, just like free trade left us with no factories, no jobs and no income. You offered to be our voice, to fight for us and drain that swamp. There is no bigger swamp than health care in America.
  • Just take a look at the disgrace called Medicaid. No, seriously, look at it. Tossing block grants over the wall to states that are even more corrupt than the federal government, and washing your hands of the whole mess, will just make things worse. Remember that the vast majority of people on Medicaid are employed. They are employed in those new and improved crappy jobs that replaced manufacturing. Medicaid is now a penny-vacuuming machine that treats both doctors and patients like trash (with all due respect to your VP). Here is a litmus test for health care plans: would your less wealthy buddies be okay with getting care through Medicaid? Are any doctors you know okay with working for Medicaid? No? Neither is anybody else. You can’t fix health care without fixing Medicaid.
I don’t know how to fix health care. No matter how loudly they scream, how certain they are that theirs is the absolute truth, and how vigorously they wave their illustrious credentials, nobody knows how to fix health care. Nobody. My suspicion is that we are trying too hard. Health care is overmedicated with solutions that have toxic side effects, for which we apply other solutions with even higher toxicity, and before you know it a mild case of the flu starts to look like metastatic cancer. So what should you do on your first day in office? Anything you want, anything at all, anything but health care.

Take your time. Find the real health care still flickering underneath the suffocating layers of Obamacare and its bloated legislative and regulatory progeny. Find real doctors who still care for the health of real patients as they did before health care became a national trough for consultants, lobbyists and other fancy thieves. Beware the experts carrying charts and graphs and big data. Ask Peter Thiel about “big data” and “machine learning” and do trust him on this one. The daunting complexity of health care is largely due to greed, fraud and treachery. If you want to make health care great again, work hard to make health care simple again.

Thursday, September 1, 2016

The Dog Whistles of Health Care

Discrimination in health care was institutionalized in Independence, Missouri on July 30, 1965 when President Johnson signed the Social Security Amendments of 1965 into law, creating “two moral frameworks for public financing of healthcare”. Medicare was supposedly an “earned” right for the elderly, while Medicaid was framed as a “welfare” program for the poor. It was a necessary political compromise. It was just a first step and bigger and better things would certainly be accomplished in due course. It was better than nothing. But fifty years later, and after taking yet another “first step” with Obamacare, the wasteful, divisive, discriminatory, and ultimately self-defeating direction we chose back in 1965, and again in 2010, has not changed one bit.

After 45 years of tinkering with Medicare and Medicaid, Obamacare in a bold stroke expanded the welfare model of medical care upwards into the heart of what used to be known as the American middle class, the former engine of progress and prosperity.  First, Obamacare expanded the Medicaid program itself to include people who are less poor than current Medicaid recipients. When Medicaid opened its doors in 1966, it provided charity health care to approximately 2% of Americans. Today, over 22% of Americans (72.6 million) and almost half of our children (35.3 million) are receiving their medical care via this welfare program and the numbers are trending sharply upwards.

Gift Horses

But the greatest innovation of Obamacare is undoubtedly the Health Insurance Marketplace, which is a brand new welfare program for the middle class. People who are not deemed poor enough to receive Medicaid charity can obtain Federal medical assistance on a means-tested sliding-scale. Largely unbeknownst to them, another 10.5 million working Americans were placed on welfare while “shopping” for health insurance in 2016.  These people are reportedly rejoicing their good fortune, because Obamacare is better than anything these people ever had, or could ever hope for.

In recent days, Aetna announced that it will drastically reduce its participation in the Obamacare marketplaces, joining a long string of other health insurers, including giants like United Healthcare and Humana, and small local outfits like Scott & White in Texas, all of which cited massive financial losses in this market. It looks like next year the many “choices” available to these people in the Obamacare marketplace will be severely curtailed, particularly in areas where poor, uneducated, low-information voters reside. The “choices” were not great to start with, seeing how most Obamacare plans rely on managed care provided by narrow networks of doctors and hospitals, and the level of charitable support is fixed, regardless of your “choice”. The optics of many choices was there to create an illusion of consumers “shopping”, as opposed to just having people apply for welfare.

The price for sparing these people the social stigma of being on welfare turned out to be not only too high, but also too low (think Escher paintings here). People who qualify for Medicaid are prohibited from “shopping” on the Obamacare marketplace, unless they are willing to forgo handouts and pay full price, because a “Marketplace insurance plan would cost more than Medicaid and usually wouldn’t offer more coverage or benefits”, and a government website proudly declares that Medicaid “generally provides a more comprehensive benefit package than private insurance”. If this is true, the Obamacare architects decided to pay private insurers on the marketplace more for less, which is not preventing insurers from bleeding cash. On the other hand, some of the same insurers, and many others, seem to be making money hand over fist in the Medicaid market which pays less for more.

How is that for a brain twister? Yes, yes, I know, if you are a physician and you accept Medicaid, you know precisely how to untwist this nasty little knot, but this narrative was not created for you. The first thing, or person (loosely speaking) to remember here is Jonathan Gruber. A while back Mr. Gruber shared with us that the guiding principles in the rooms where Obamacare was designed were that American voters are stupid and that lack of transparency is a good thing. It should be obvious by now that the introduction of Obamacare to the public was false and its initial incarnation, chockfull of choices, “subsidies”, marketplace “shopping” and all, was (designed to be?) temporary. But hey, it was just a first step and it was better than nothing. So what’s next?

The Morning After

As is the custom in our great nation, now that Obamacare marketplaces have been exposed as the hoax they really are, the cheerleading section is transitioning to its Monday morning role of funeral criers. Every ‘splaining media outlet is diving into lengthy treatises about risk pools, moral hazard, actuarial values, complete with charts and “I told you so” interviews on how to salvage the situation. The government, as usual, is doubling down on the “everything is (still) awesome” anthem of planned stagnation. Insurers leaving the marketplace are a sign of normal competitive business. Sky rocketing premiums are a result of initial underpricing of products. Things will eventually even out. And besides, why worry your little head about premiums going up or down, if the government is paying for the ride?

See, the more the premiums go up in 2017, the more people would be able to pay less for marketplace plans. This is because very poor people are disproportionately more likely to use the Obamacare marketplace, and these people seem to have a predilection for cheap health insurance plans. Theoretically, all Americans except the 20% or so at the top (the fifth highest income quintile), are eligible for welfare in the marketplace if their stars fall slightly out of alignment. Right now, the self-appointed elites are piloting this marketplace solution for people who have few if any choices in life in general, but make no mistake, the forthcoming rollout to the rest of us will be fast and furious.

After you read a dozen or so articles on the subject, several options surface as the popular wisdom of the unpopular elite minority who won’t be caught dead anywhere near an Obamacare marketplace:
  • On autoplay since 2012 – Repeal and replace the whole darn thing with something really good.
  • Whistling past the graveyard – Stay on target. Ignore the noise. Keep pushing the happy narrative. Nothing to see here. Next year will be better.
  • Pedal to the metal – Add some serious fangs to the individual mandate. Force insurers to eat their marketplace veggies if they want public cash desserts.
  • Resurrection – Remind me, why did we drop that “public option”? What was it again?
Plebeian logic says that at least for the immediate future we will be whistling past the graveyard of health care in America. After that, as strange as it may sound (go ahead and bookmark this), they will be rolling all four option into one grand solution.

The Pauper Option

If you are eligible for Medicaid in the state of Louisiana for example, you have five choices, which is more than some Obamacare marketplace “shoppers” have. On the Healthy Louisiana website, you can enroll, select a plan, compare plans, compare networks of providers, and compare plan benefits, including co-pays, cash rewards for healthy behavior, free cell phones and even free diapers and school supplies. Is this a marketplace? I think Healthy Louisiana is as much a marketplace as the Obamacare Venezuelan shopping mall. It provides infinitely more information. It includes plans from Obamacare quitters, such as Aetna and United Healthcare. The state pays less, beneficiaries get more, and insurers make very nice profits.

In Baton Rouge, there is one (1) oncologist in the United Healthcare network and zero (0) plastic surgeons in the Aetna network. Sometimes, you just have to travel to New Orleans, Shreveport or Lafayette. It’s only a few hours by car. Most people don’t need oncologists and plastic surgeons. Most people are perfectly fine just having 100 family practitioners, almost half of which are doctors.  In Louisiana, Medicaid pays $41.53 for a typical office visit (99213), which is a bit more than half the Medicare rate, and usually less than half of what private insurers pay. With a full time schedule, and average overhead, a primary care doctor seeing nothing but Medicaid patients in Louisiana, will end up with $100,000 to $130,000 a year before tax.

This is the secret sauce. This is what’s missing from the Obamacare marketplaces. There may be room for additional tinkering with networks, but it won’t be enough. The only way to bring costs down is to attack the supply chain. Like Walmart. Like Medicaid. But you can’t do it if you have to compete in earnest, because you will lose all your suppliers. Everybody has to do it together, and that would be collusion. So you either merge & acquire until you are the sole insurance provider in a market, or you make the government do it for you. Either way, we end up with a marketplace of Medicaid plans. Like Healthy Louisiana.

Before you argue that physicians will just stop accepting Obamacare marketplace plans, remember that many, many doctors do take Medicaid and adding 12.5 million people from the marketplace to the 72.6 million already on Medicaid is not a big deal at all. This is why insurers that specialize in Medicaid do better on the Obamacare exchanges. It’s not that they know how to manage these people. They know where to find and how to manage these doctors.

They probably won’t call it Medicaid. Maybe Medimart will be acceptable. It will most likely cost a little more to maintain the appearance of respectability, at least for a while, but this is a generous program for these people. The line is drawn at 400% Federal Poverty Level (FPL), and as the global sharing economy grows, and as employers begin to see the light, those who can’t quite reach six figures incomes, eighty percent of people in America, will be “shopping” at Medimart, because that’s what these people do.

Monday, August 8, 2016

Open Letter to Senator Bernie Sanders

Dear Bernie,

I was one of the gullible liberals who thought and vehemently argued for months on end that you could win the Democratic Primaries fair and square. After all if a rookie billionaire with zero political credibility and a spotted past could win the Republican nomination, why wouldn’t an unimpeachable United States Senator be able to do the same in my party? We both know the answer(s) to that, don’t we, Senator? You chose the high road when all was said and done, but was that the right road? I have no doubt that your entire career and this ill-fated campaign in particular were driven by a desire to lift the exploited, the downtrodden, the poor and the excluded to their rightful place in a government of the people, by the people, for the people. In which case, Senator, you are now squandering the opportunity of a lifetime to change history in a way no one else can, or ever could, or will ever be able to even try.

You may be telling yourself that once you failed to win from the outside, the smart choice was to fight from the inside. You may be taking great pride from that lefty progressive platform you managed to negotiate. When was the last time any President felt hamstrung or guided in any way by the party platform? Ninety-nine percent of the public doesn’t know what the party platform looks like. It’s an empty achievement, and you probably know that. There will be no fight for fifteen. There will be no free college. There will be no extended family leave, no pay equity and certainly no single payer health care. And there will be no end in sight to the steady hemorrhage of middle class jobs to slave labor countries. But I’m sure you know this too, Senator.

Nobody is going to bother the venerable Wall Street institutions hanging around our collective neck like a rock. Nobody is going to lose sleep over the Silicon Valley technology cartel, which is quickly acquiring more power than the biggest bank ever had. And there will be war, Senator Sanders, as sure as I am sitting here and you are sitting there, there will be war. With a little bit of luck, it will be an old fashioned cold war that will further impoverish the nation and strip citizens of even more civil rights. If luck runs out, and it will, Americans will again die in some God forsaken desert with an unpronounceable name, to “protect our freedom”.

How do you feel, Senator, when you watch the swarm of millionaires and billionaires coalescing around the candidate you endorsed? Michael Bloomberg, Warren Buffet, Mark Cuban and now Meg Whitman, are all praising your former opponent and promising to fund her campaign. Heck, even the Koch Brothers seem sympathetic to her cause, not to mention the deluge of conservative purists crossing party lines spontaneously or after being actively wooed by the Democratic candidate running on the most progressive platform ever. Your preferred candidate said that our cause is her cause, and this must be why hedge-fund managers rewarded her with something like $50 million in campaign “donations” (so far). Do you think any of these powerful interests gives a rat’s ass about our political revolution?

Have you noticed, Senator, how the only places where your name is still spoken are Trump rallies? The much touted shift to the left in the Democratic Party ended abruptly when the television cameras were powered off in the Wells Fargo arena in Philadelphia. The impressive array of professional exploiters of humanity, and the planet we live in, who are stepping all over each other to swear allegiance to the Democratic candidate is matched only by the unbridled enthusiasm of the hired guns of the corporate media. There will be no campaign finance reform, no end to fossil fuel indecency, no end to fracking and drilling and pillaging and slashing and burning, but it will all take place with the utmost respect for stately decorum. Was this your vision for our future back in April of 2015, Senator? It wasn’t ours.

Our $27 voices have been silenced when you decided to suspend yours, and frankly Senator Sanders, I don’t think that decision was entirely up to you. This was not a regular primary season where one can barely tell the difference between campaigns before they all merge into one bland compromise. As you said many times, this was indeed a revolution. Yes, you sparked the flame, Senator, but we build the fire. It wasn’t yours to do as you please with, and you were certainly not empowered to deliver “your supporters” to the subjugation of the status-quo. To put it in terms everybody understands these days, we funded this revolutionary venture with our hard earned money and our feet, and you, Senator, had a fiduciary responsibility to your shareholders.

We lost one battle and you conceded the war. We can’t undo the loss, but you can undo the concession to some extent. You can at least try to make things right for people whose $27 investment represents a week’s worth of food. On a personal level, you have much to lose if you do this, but when you fan the flames of revolution (even a political one), personal sacrifice is baked into the cake. You should have known that, Senator, and you should have made peace with that from the start. I have to confess here that I am not entirely surprised by your decision. Your acquiescing response to subtle and not so subtle efforts to coopt this political revolution, by what I consider unsavory actors, was in my mind a harbinger of things to come. And things came.

I’m not asking you, Senator, to get out there and campaign for “the other” movement propped up by millions of small donations from people who can’t afford to donate either. I am asking you to recognize in your heart of hearts that the road of our political revolution does not go through another Clinton administration. I am asking you to recognize that eight more years of keeping people down, while fraudulently posing as their champion, are far more devastating for our revolution, this nation, and the world at large, than a Trump administration could ever be. These are desperate times for most of us, so I am asking you Senator Sanders, to remember that you have a responsibility, nay, a duty, to stand up one more time and help us keep hope alive, Sir.

Monday, August 1, 2016

Cyberwar, what is it good for?

Some wars are supposed to last forever. Lyndon B. Johnson started a war on poverty. Richard Nixon kicked off a war on drugs. Ronald Reagan initiated a war on terror. Poverty, drug use and terror are booming. It’s time to launch another good ol’ war. Let’s make it relevant, cool, hip and infinite. So how about a 21st century war on Cybertheft?  This may sound trifle by comparison to those other wars, but wars are rarely about the actual title we bestow upon them. The war on terror evolved into a war on people living under secular dictators, the war on poverty ended up being a war on poor people, and the war on drugs became a war on black people. The war on Cybertheft will be the war on all people everywhere.

The war on Cybertheft has been simmering since the banks decided to do business online. The threat of “identity theft” should have been a monumentally mobilizing battle cry. But it wasn’t. Oh sure, it spawned a bunch of fear inducing exposés and some mildly successful businesses, but all in all, it failed to generate the zombie apocalypse panic it was supposed to trigger. Luckily, our wise leaders decided to put all our medical information on the Internet. It’s one thing for a Romanian hacker to gain access to your checking account balance, and quite another if Marcel is suddenly able to peruse your history of vaginal yeast infections. It makes no sense really, but the latter seems like an unbearable and humiliating violation of who you are. Wars have been launched for much less than that.

Let me give you an example that is splashed all over the news lately. A nondescript bunch of hackers broke into Democratic Party servers, stole all sorts of documents and emails and provided them to WikiLeaks for publication. This incident proved to be an embarrassment for the global money cartel behind our democratic curtain, and at the same time a great opportunity to score some cheap points in this weird election while stoking the fires of war. Within 24 hours, and with ample assist from corporate media tools, the conversation moved from corrupt, political machinations to an alternate universe where the Kremlin is colluding with insurgents to overthrow the rightful rulers of America. Terrifying stuff.

Back to medical records. There is a major, and very public, wringing of hands in policy and technology circles on how to safeguard the privacy and security of computerized medical records. Huge health care databases seem to get hacked almost on a daily basis. Shady hackers are advertising stolen medical records for sale on the “dark” web. The term “ransomware” is entering the health care vernacular (i.e. hackers asking health related entities to pay for keeping security breaches secret). Some experts say that thieves engage in fraudulent billing (it is a bit unclear to me how a fraudster makes money when the hospital charges you for a fake surgery, unless the hospital is stealing its own data). Other experts are hypothesizing that medical data could be used for personal blackmail (with not one shred of evidence). Hackers are posting screenshots of EMRs saying that this is the data they “stole” (although gaining access to an EMR is not equivalent to having its data). Pretty scary stuff here too, no?

But here is what is not happening. You don’t see curated lists of famous people treated for cooties. You don’t see lists of women who had abortions or of politicians suffering from palmar hyperhidrosis. You don’t really see anything that could be due to theft of strictly medical information and the “samples” posted by hackers are about Social Security numbers, dates of birth, addresses, phone numbers, emails and all the stuff you can steal from a bank. Is this a big deal?  Maybe, but judging by the number and magnitude of security breaches in the last few years, there must be dozens upon dozens of copies of our financial data floating out there and frankly, people seem rather oblivious to the whole thing. We can’t have that. We need some pizzas, some fireworks, like they have in politics.

As I’m writing this, more Democratic Party servers are being hacked, prompting increasingly unhinged conspiracy theories to justify a reboot of the Cold War with Russia, and if we’re lucky a real war. You see, in this election we unfortunately have one candidate who didn’t get the memo outlining the benefits of a nuclear war with Russia. Blabbering about NATO’s lack of purpose and how nice it would be to get along with Putin is not moving us forward. Watching CNN or reading The New York Times or the neo-conservative rags, is like watching a train wreck in slow motion. The Cybertheft attacks on Democratic Party servers are worse than Watergate, maybe worse than Pearl Harbor or 9/11, it’s an attack on our Nation, and there should be stern consequences (did you notice the unusual patriotic rah-rah at this year’s Democratic convention?).

America, we’re under attack. We are being Cyber-attacked on our own soil. A foreign power is attempting regime change in our country by exposing the dirty electioneering of the party currently in power. The question is not how come we have banana republic electioneering. The question is how come Putin dares to point that out. We don’t know if Putin did any such thing, but the theoretical possibility that he might have, or may do so in the future, is reason enough to perhaps slap some more sanctions somewhere, or move a few tanks or submarines closer to the missile shield we just deployed in Romania (?) to protect it from Iran (?). So Annie, get your guns, because Cyberwar is just the prelude.

In health care the war on Cybertheft of essentially financial data is a front for facilitating massive trafficking in actual medical information. The government agencies in charge of health information technology are accelerating the good fight to “protect” security and privacy with its quintessential tools of building awareness, promulgating regulations and funding the creation and enforcement of more regulations. But the war on who gets to be the king cyber thief is getting a bit more interesting, and perhaps more important to humanity, than the Russia-bad-America-good games played on the global theater stage, because while the public is being distracted by the legends of “TheDarkOverlord” who is stealing and selling disconnected phone numbers, the data cartel is emptying the vaults of our collective human dignity.

It was Google that invented the idea of data “liberation” to put a progressive face on its efforts to amass and sell access to personal information. It was the disruptive innovation lobby in health care that ported the data liberation movement to health care in the hopes of lowering the barriers to entry in an exceedingly complex and saturated market. The government bought the idea lock, stock and barrel because governments love surveillance of citizens and because our government is in bed with, or in the pocket of, giant technology companies aspiring to liberate a piece of the $3 Trillion health care market. But something strange happened on the way to data without borders. The government decided to fund Precision Medicine and it awarded the biggest chunk of money to the most vocal advocates for the creative destruction of imprecise medicine.

It didn’t take long to figure out that an academic medical center, as flush with cash as it may be, is no match for Google or Apple when it comes to stealing personal information from millions of people. And it didn’t take long to figure out that data liberation is set up to work in one direction and one direction only – from everywhere, into Google, Apple and other mega-rich Silicon Valley companies.  So after years of pushing the free-market miracles of iPhone medicine and genomic tests, it’s time to demand that government declares personal information to be a “public good” confiscated at will and freely available to tech giants and researchers, because anything else would be, wait for it, racist. Yes, racist, like in discriminatory against non-white minorities. The only thing left to ponder is whether we will be destroyed quickly by external weaponry, or extinguished slowly from the inside out.

On January 17, 1961 President Dwight Eisenhower delivered his farewell address, warning the nation of what he called the military-industrial complex: “In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military-industrial complex. The potential for the disastrous rise of misplaced power exists and will persist.” Note the wonderful nuance when he says “sought or unsought”. Whatever arguments, apologies, explanations, justification you may be inclined to offer, that “unwarranted influence” is undeniably here. We chose not to heed Ike’s warning and have been paying in blood and treasure ever since. The balloon payment is right around the corner.

And Ike had one more lesser known warning: “For every old blackboard there are now hundreds of new electronic computers. The prospect of domination of the nation's scholars by Federal employment, project allocations, and the power of money is ever present – and is gravely to be regarded. Yet, in holding scientific research and discovery in respect, as we should, we must also be alert to the equal and opposite danger that public policy could itself become the captive of a scientific-technological elite.” He saw it clearly. He saw it coming more clearly than we, who are living in it, are seeing it today. From half a century away, Dwight Eisenhower saw the forest in which we wander, lost amongst the trees.

Wednesday, July 6, 2016

Brexit, MACRA and the Price of Tea in China

MACRA seems to be the talk of the town right now. MACRA and MIPS and APM and the dozens of sub-acronyms flying around like so many arrows in this Game of Thrones, Battle of the Bastards. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law over a year ago. That’s right, MACRA is the “law of the land” now, and it became law of the land with overwhelming bipartisan support in Congress and with much lobbying and cheerleading from medical associations. MACRA is not a proposal. It’s not some random regulation. It’s not something that can be stopped or changed without an act of Congress.

And MACRA is very lengthy and very detailed legislation. There is nothing surprising or unexpected in the recent publication of proposed implementation details that was not spelled out in the original MACRA text. It is possible that the degree of specificity in the CMS proposed rules for MACRA implementation finally hit home with the clarity absent from typical legislative language. It is also possible that an actual implementation date a few months down the road is more threatening than one that is a few years out. Either way, we are now witnessing a flurry of social media chatter lamenting MACRA, asking for changes in MACRA and demanding to stop MACRA altogether. I hate to say it, but all this huffing and puffing is a day late and a dollar short, folks.

Amongst the avalanche of angry articles, militant tweets, desperate conversations, calls for action (commenting on the proposed rules), apologies and condescending propaganda, perhaps the most touching post I’ve seen came from David Introcaso at The Health Care Blog, which shows in great detail how the MACRA is not really measuring “value”. Dear David, MACRA wasn’t meant to measure anything. It wasn’t meant to improve anything. It was meant solely to aid and abet the McDonaldization of health care. Submitting MACRA comments to the CMS is like bickering over the choice of rope after being sentenced to hang by the neck until you are dead.

Efficient, quantifiable, homogenized, controlled and dehumanized, that’s what health care must become, and when it does, health care will be plentiful, easily accessible and affordable for all poor people everywhere. Like Happy Meals. So how do we fight this? If you’re a physician in a leadership position, you don’t. Why should you? The more money we can save by cutting down “inappropriate utilization”, and the more money we can save by penalizing working doctors, the more cash will become available for executive bonuses. If you are a physician entrepreneur, you have bigger fish to fry. This is your once in a lifetime opportunity to invent a Zuckerberg platform for health care or a Bezos venue for online health care. If you just see patients from dawn to dusk, well, why are you doing that? There are leadership programs and entrepreneurial classes for doctors sprouting everywhere.

If you’re old fashioned or driven by idealistic notions, get over it. We live in a globalized economy. We don’t live on Planet Earth. We don’t live in a global village, or even a globalized society. We don’t even live in the Matrix. We live in the economy. It’s the economy, stupid. It’s like the Serengeti, dumbass. Migratory herds of wildebeests, zebras, antelopes, whose sole purpose in life is to be eaten by big cats. Is there a way out? Can the wildebeests, stop as one, turn around as one, and vanquish the predators? They tried that in Great Britain the other day. They called it Brexit. The globalized economy is still reeling from that blow, and every fat cat, every hyena, every vulture and every maggot, mobilized to define the Brexiters as a bunch of racist, bigoted, uneducated, mentally challenged, Luddite, toothless old farts, too stupid to appreciate the majestic beauty of the Serengeti.

On my Twitter stream some of the more frustrated physicians suggest that perhaps doctors should take a page from the Brits and stage a Drexit. True, revolution is contagious, but what does the doctor plight have to do with Brexit and globalization?

Post Brexitum Ante Drexitum

On June 23rd the people of Great Britain decided by referendum that European Union technocrats, congregating in Brussels Belgium, shall no longer be empowered to dictate which tea kettle an Englishman can or cannot use. The Brexit was essentially a vote against globalization, against a common regulatory framework and against the free movement of labor to support a common market where the rich get richer, the middle classes gets poorer, and the poor get to work for a bowl of thin gruel. Globalization has been excellent for the elites and not too shabby for a slice of society immediately under the elites, while gutting the vast majority below. And the gutted majority was supposed to meekly accept the inevitability of this new world order. Is this starting to ring your liberty bell?

There are approximately one million medical school graduates in the U.S. Of those, a small number are considered elites. These are the CEOs of big companies, the CMOs and CMIOs, the board members of every kooky startup, those who give keynote addresses at industry shindigs, those who write books, give interviews and do podcasts, those who shape and promote government agendas. Then come the thousands of highly specialized physicians who make money by the boatloads and are shielded from reality (for now).  At the lower end are all other working doctors, with primary care bringing up the massive rear. The distribution of riches and pain seems similar to the UK, the US, and frankly, to a host of other third world countries.

Whereas working people are told that they suffer from “anxiety” and various “phobias” (and stupidity), doctors are labeled “burned out” or “suicidal” (or disruptive) when failing to live up to the McDonaldization of life in the global economy. The elites of course are immune to these afflictions due to their superior visionary intellect. The rest of us need to be gently “nudged” to alter our “behavior”. Physicians need to have their “culture” and “readiness to change” evaluated. We all seem to need remedial education for how to “communicate”, how to “transform” or “adopt change”, how to be “sensitive”, and how to be grateful for all the unearned “privileges” we enjoy while billions of others are worse off. My grandma used to make similar arguments for why we should eat her revolting creamed spinach, but let’s go back to globalization.

Globalized Health Care

Remember when we used to say that all health care is local? We don’t say that anymore. Now we have centers of excellence far away from home and small rural hospitals that are all but doomed. Dr. Phil and Sir Richard Branson want me to get medical advice from strangers in other states. My TV frequently advertises state of the art hospitals in Dubai. Transcription services, claims processing, utilization reviews, and even radiology services have been globalized already. As technology pushes itself into medicine, with apps and artificial intelligence and even those pedestrian EHRs, remember that computers, tablets, phones and such, are all made in China’s slave labor camps, software is largely made in India or Pakistan or by imported slave laborers, maintenance and help desks are mostly overseas and some are in private American jails.

The lethal combo of HITECH/ACA/MACRA is essentially a redistribution of payments from local doctors (and the local people they employ) to cheaper semi-skilled and unskilled labor across state lines and across the globe. The benefits accrue to global corporations directly and indirectly, because profits in globalized business models are much larger, and the locus of power is shifted from geographically anchored professional expertise to global technocrats. This is not a disruptive innovation. From the days of Nebuchadnezzar to the East India Company and beyond, those who wished to rule the world understood that commandeering and destroying local infrastructure and uprooting people are the best ways to foster compliance with centralized governments far away.

Hard Drexit vs Soft Drexit

Unlike the Brexiters, physicians have no country of their own, and the Gomer Blog notwithstanding, there is no mechanism for a referendum. There is no Union or Guild or national body that could allow doctors to organize a serious Drexit that will pull all doctors, or at least a critical mass of practitioners, out of the acronym games. But even if a Physician Union existed, it is not clear what doctors would want to exit. Do they opt out of Medicare and Medicaid en masse? Do they opt out of all insurance contracts, because they are essentially the same? Not likely. Perhaps a small number of physicians who provide the least expensive services could survive in cash only practices, but the vast majority could not. And the producers of HITECH/ACA/MACRA know too well that this kind of Drexit is not an option.

But there is a softer type of Drexit. One choice is to pay for protection. This is a time honored method for keeping bad guys from raiding your small business. There are companies, health systems and even insurers that will bundle physicians of all specialties into large organizations to better cope with large regulatory climates designed for the global economy. Theoretically, you can remain independent in such arrangements. Theoretically. The other choice is an equally time honored method for standing your ground. Civil disobedience.

You don’t have to comply. Nobody is going to take your medical license away, and considering the meager ratio of physicians to population, nobody is going to prevent you from seeing patients. They will however pay you a bit less than if you complied with HITECH/ACA/MACRA. Think of it as an independence tax (low single digit percentages) over the next decade or so. If you sit down and calculate the price you’d have to pay for compliance with regulations, including opportunity costs, you will find that civil disobedience puts you slightly ahead or, at the very least, it breaks even with compliance.

Bottom line here is that you need to do your own math. Ignore the rhetoric. Ignore the doomsayers and the saviors of mankind. Every single person who opens their mouth on this subject has a vested interest that may or may not align with your interests, and the interests of your patients. Remember that the technocrats at the CMS are forecasting that you will be taxed no matter what you do, so why spend money and effort on a rigged game?

Instead, turn it around. Refuse to serve in the army of globalization on moral and ethical grounds. Wear it like a badge of honor. Advertise your Drexit. Make a poster for your clinic. Put it on your website. Stand with your patients. Let them know that you put patients first and money a distant second. Be a conscientious objector to a world order where we the people don’t matter anymore.