BY MARK BALLARD, MD | SEPTEMBER 12, 2012
Empty chairs and Obamacare
This election year, and the last four years, has seen a myriad of opinions, bipartisanship, and no easy solutions in healthcare. Politics and healthcare make strange bedfellows. Moreover the debate over the solutions to rising healthcare costs go beyond pillow talk and take place with too many “Empty Chairs” at the table. The comic characterization was Clint Eastwood speaking to an empty chair last week during the RNC. This was poignant and honest comedy and I give him two thumbs up. Perhaps as we close in on Election Day the debate won’t be a monologue to the empty chair of opinion spinning. In the last sixty years, the U.S. healthcare system has morphed into a system successful at treating most diseases, but hugely preventive. Although certain politicians may want you to believe differently, preventive medicine didn’t begin with the passage of the Affordable Care Act. Most primary care appointments are for preventive measures like hypertension, cholesterol and diabetes control. Some would call these chronic diseases but I maintain it is mostly preventive.
This is in contrast to the first part of the 20th century when one saw the old “sawbones” for appendicitis and broken bones. People didn’t go to the doctor unless they had a problem. There were no antibiotics and most communicable diseases were controlled by public health measures, something that was forgotten unfortunately in the early days of AIDS. When hypertension and FDR’s hypertensive encephalopathic incapacity was correlated during the Treaty of Malta that all changed. As a physician I feel obliged to address the issues of the American medical system and the vast improvement in our health and longevity, in no small part due to the active pursuit of drug discoveries. Over the last 60 years life expectancy has increased by more than ten years regardless of sex and race! While giving lip service to a new commitment for science (and medical) education, I worry about the negative messaging that we hear from media and Washington regarding anything scientific. Stories of success and medical breakthroughs are overshadowed by negative press on medical spending, pharmaceutical profits, and negative comparisons to other countries’ healthcare.
As the need for science and technology increases and the rest of the world catches up to our level of technology, the message our students are seeing and hearing is why would anyone want to choose a scientific or medical career? Why go into debt by thousands of dollars to get that education? There is little incentive to take a risk on starting a business. I totally agree that teachers, police, and firefighters are underpaid but now we are witnessing the demonization of any career other than government employment. I was blessed to hear President Obama’s Arizona State University commencement speech in 2009. In effect he said if you can’t get a job, and there were a lot of engineering students that didn’t get a job that year, just volunteer for a charity organization. I have done my share of charity work and appreciate its importance. Unfortunately it doesn’t pay off the student loans nor do anything to beef up a new graduate’s resume. The best way I found to contribute to the needy is like most physicians, donating care on a daily basis in one’s own business and do missionary work both home and abroad on vacations. Liberals believe it is the government’s right to give to the needy (as if there’s no strings attached?) There are many reasons politicians give bad advice and thinking that government knows best. The problem is: memory of what they say and the research they do is limited by the next election cycle.
For example, I remember listening to Hillary Clinton (then the First Lady) give a speech during the NOW National Org. of Women) convention in 1993 and her telling the audience (paraphrased), “If your Doctor doesn’t order a yearly mammogram, you demand it.” I was trained in preventive guidelines and totally agreed and tried daily to convince patients to comply (like smoking cessation, BP control and lifestyle changes.) But why was a politician trying to practice medicine and why didn’t she include physicians on her healthcare panel? We could’ve told her secret health task force that physicians also demanded our patients get yearly screening mammograms but Medicare, a government program, refused to pay for these mammograms but every three years. Our patients would respond, “If our Medicare doesn’t pay for it then it must be unnecessary and you must be ordering it to get a kickback.” I had my first realization that something sinister was entering into the physician-patient relationship. Now, the United States Preventive Services Task Force (USPSTF) issued new guidelines in 2009 that say wait until a woman reaches 50 years of age and get a mammogram every 2 years after that. Their website also has helpful information such as “Too much prevention: what not to do in the primary care setting.”
Fast forward to an Obama speech when he was blaming Bush for creating the ballooning budget deficit, in part due to the passage of Medicare Part D (expanded medication coverage for seniors.) Part D was an option that covers most of the pharmaceutical expenses except when spending went over $2700 then the patient would cover the next $3300 (this amount changed every year until its disappearance, in the original scenario) Part D would then kick in again.
This break in coverage, coined the “doughnut hole,” was for cost savings, insuring the program wouldn’t break the government’s budget in the early years. Of course Obama also stated that the mean old pharmaceutical companies were the only ones that would profit from such an idea. But in the very next sentence he said, (paraphrased) “I will also close that doughnut hole so seniors can afford all their meds.” Wait a minute, the doughnut hole was phasing out any way and didn’t he just get through chastising Bush for creating the program; wouldn’t expanding it now be more budget busting?
Another Obama speech involved cutting waste. Everyone agrees waste and fraud reduction should be addressed especially with all of those scooter stores advertising on TV. But he was talking about Medicare Advantage, an HMO-like program that included preventive care measures. The program had been formed to also save money but as most physicians (and anyone with common sense) know preventive care costs more up front but saves money in the long run with early detection especially in the aging population. The government had been paying insurance companies to administer the program but it was running at 112%, 12% over traditional Medicare. This was what Obama was calling “waste.” Then in the next sentence he started touting his universal health insurance as finally a health plan that was offering preventive care. But wait another minute, isn’t that what Medicare Advantage was offering? Or was this a blatant attempt to steal from the Medicare population and give the same benefits to the uninsured including illegal aliens in the U.S.? There was precedent however with transfer of $716 Billion from Medicare to fund ACA after its passage. Further explanation from the government – this was not stealing from the seniors because the biggest portion came from cutting annual increases in Medicare payments to medical providers. Soon, if not already, medical providers won’t be able to afford to care for Medicare patients. Their overhead is going up, not down, especially without tort reform.
Thanks to the efforts of healthcare think-tanks such as the National Institutes of Health, medical care has excelled in developing evidence-based guidelines, legitimately saving lives and reducing unnecessary expenditures. Now the government has turned to their own pseudo-science and it’s called cost-effectiveness research. This is the smoke and mirrors in the hands of government run healthcare, as they set out to prove that the cheapest alternative treatment is always the best even when common sense says it sometimes isn’t. And now what does Hillary Clinton think of her own government saying yearly mammograms aren’t cost effective? Oh well it’s another election cycle and who remembers. And without tort reform patients can still sue the physician who didn’t order a screen that government guidelines say isn’t necessary! Do we really want to turn these decisions over to bureaucrats who, just because they say it, we will all believe it is for the best? Guidelines do change over time but working together to find the correct adaptation to new findings would be preferred.
Today’s medical care has become expensive but not bad. Have we forgotten the historical importance of medical advances? Does anybody remember gallbladder and knee surgery before endoscopy and prostate surgery before robotics? The side effects of the early hypertension meds (and resulting poor compliance) prior to ACE inhibitors, Calcium channel blockers and selective beta blockers? On a good day you could faint, be impotent (B.V. - Before Viagra), depressed and congested but you wouldn’t have a heart attack at age 50. Does anyone remember the times before acid blockers such as Tagamet and proton pump inhibitors when the treatment for peptic ulcers was surgery? When aspirin was the only drug for aches and pains (other than opiates) that caused ringing in your ears, kidney damage and bleeding ulcers? Who doesn’t take a statin for cholesterol and who doesn’t live a longer and more productive life because of medical advances? And because everything has been discovered can’t we learn to live better with the medicines (hopefully they are generic or soon will be) and surgical advances we already have?
I now work in research and see the benefits of R and D daily. There are hundreds of orphan diseases that now have treatment hopes. They call them orphan diseases because they aren’t big enough to generate an interest for government-funding or philanthropic organizations. While the big diseases like breast cancer, heart disease and Alzheimer’s compete for dollars, fortunately drug companies are finding cures and treatments for what would be a neglected part of our society. And just like Styrofoam, developed during the early days of NASA, is now available for the benefit of mankind, the drug pathway discoveries of these orphan diseases hold great promise for treating more common illnesses such as arthritis and emphysema. This is the win-win of free enterprise. Medical science is on the verge of understanding the human genome and the hope of individually tailoring treatment based on one’s genetic and phenotypic character. Will we have the resources to advance personalized medical treatment and improve on medical science? If these bureaucrats, lawyers and politicians take over, I doubt it.
These are but a few examples; however the same faction will have you believing that the only accomplishment has been to make these pharmaceutical giants rich. Already mentioned are the fantastic discoveries and breakthroughs in our preventing, understanding and treatment of disease. These advances aren’t just for the rich, especially as patents expire and drugs go generic; we have all benefited without prejudice and no one gets turned away from the emergency room as it’s a law. Let’s look at the facts – generic manufacturing of common drugs for hypertension, diabetes, cholesterol, arthritis, etc. have saved the U.S. almost ONE TRILLION DOLLARS in the last decade! The demand to correct, medicinally, our overindulgences cannot be trivialized as a cause for increased spending. Like the Dave Matthews song, we eat, drink, want, and play too much and our over-indulgences have required quite an expenditure on healthcare costs. The “Talking Heads” focus blame on the healthcare “Industry.” It would make more sense to have an inclusive conversation and hammer out a uniquely American solution, one that eliminates pre-existing conditions, frivolous lawsuits, huge administrative insurance costs, and rationing to name only a few.
Then there was the Obama speech to the AMA, also early in his Presidency. He was explaining his plan and ended by stating there will be “NO TORT REFORM” included in his plan. No explanation, no “let’s work together on this, just “NO TORT REFORM.” The costs of defensive medicine are highly debated, but some estimates are up to 50 percent! Just ask any physician and he will tell you that fear of lawsuits and adhering to standards of care is always in the back of their mind. Explaining the pros and cons of any treatment especially in the big city is difficult as well as time-consuming. Healthcare think-tank’s and physician surveys estimate the cost of practicing defensively is between 26-34% of the total cost. These figures include practicing “rule-out medicine” rather than “diagnostic medicine” out of fear that they will miss a diagnosis and be sued. Surveys also found that defensive medicine decreases patients’ access to healthcare, delaying adoption of new medical techniques, procedures and treatments due to fear of lawsuits, and lastly defensive medicine will adversely impact the physician shortage.
But who will protect the public from these butchers and incompetents that won’t even get electronic medical records? Other developed countries such as the UK and Canada don’t need the protection afforded by these legal eagles. The real reason the trial lawyers don’t want tort reform is simply because they will lose money. In a state like Indiana which has tort reform and arbitration panels, lawyers won’t take a case if they will have to put in too many hours or if there is a cap on awards. So if you are a Medicare patient with no dependents, no loss of future earnings, and had a delayed or mis-diagnosed disease who protects you? Not trial lawyers because forty-percent contingency fees isn’t enough when awards are limited!
Another example is seen daily on TV, “Did you die taking this drug or that drug? Call our offices right now at 1-800-BAD DRUG.” The bad drug is actually a non-generic advancement over the old drugs that are generic and the companies that make the new advanced drugs who have deep pockets and finally making ROI (return on investment.) This is in spite of the expense of getting a new drug to market such as newer, safer anti-coagulants that don’t require lab tests, as a replacement of a generic called Coumadin, otherwise known as “rat poison.” This rat poison has been around, as the only alternative for treating clotting disorders and arrhythmias, and has “killed” thousands while helping millions. It requires at least monthly blood monitoring because of a narrow therapeutic window and constant dose adjustment if your clotting is too low or high. The problem is it has saved a lot more lives than hurt. This is called risk/benefit. The problem is a lawyer knows there are no moneys to go after damages from an old generic drug. If politicians and lawyers take over healthcare it will always be about the money or power even to the point of denying services and rationing. Believe what you want, even though everyone should want to earn a living physicians will also always strive to do what’s best for their patients; the Hippocratic Oath means something to them but nothing to lawyers and MBA’s! Or you can pay your attorney by the minute the next time you call him or be placed on hold for that government bureaucrat to approve your care.
In the good old days, docs were said to have made lots of money by keeping patients in the hospital for “checkups” and insuring they wouldn’t have to be readmitted. Things have changed dramatically with length of stay guidelines and we all have embraced these cost-saving changes, even though out-patient surgeries and colonoscopies have hardships and required adjustments. Mayo Clinic has done pretty well finding clients who will pay out of pocket to get everything done during a single hospitalization, as opposed to the fragmentary care insurance companies require. This “old-fashioned” method of treating patients went away with HMOs, DRGs and the healthcare system’s desire to control costs and wrestle control from the physicians who supposedly profited from the system. It put the control in the hands of MBAs, hospital administrators and insurance companies who know how to properly run a business. They turned patients into customers and told everyone they would save the system from bankruptcy. Somehow that goal hasn’t been reached. With the need to discharge as soon as possible, the readmission problem has gotten worse. I may be biased but costs are much worse since the addition of another layer of decision makers.
I didn’t want to be “God” to my patients; I wanted to be their decision-making partner. Of course that ended the first time I laid out treatment options, the pros and cons, to a patient and they responded, “You’re the doctor, you tell me what to do!” I trained in the modern era of medicine, as opposed to the “Golden Age” that came before, where physicians were Gods. I also intended to practice preventive medicine. It started out that way, before copays and when office visits were $17, or a trade for fresh vegetables from their home garden. As a primary care physician in my early days of private practice I set up my shingle with the intention of seeing my patients through at least four generations and taking care of all their needs and referring when I couldn’t treat them properly. I delivered their babies, circumcised them, assisted the surgeon when their gallbladder bloated up, and took care of Grandma in the nursing home, just like my senior partner did. Growing up and setting up shop in a small Midwestern town until retirement or premature death from stress and overwork was all I could envision. The physician-patient relationship was truly that, a partnership where we would advocate for them (against the insurance companies,) not write down a diagnosis (if it might endanger their insurance coverage) and listen; that was enough and a lot more than you can get from specialists. Listening has become a lost art I hear, just like physical diagnosis; “laying on of the hands” was replaced by this scan or that specialist. Physicians have been protesting against insurance companies that jacked premiums and denied pre-existing conditions for a long time, a lot longer than the Affordable Care Act that made it illegal. Let me restate this, “Why does it take an act of Congress to right a wrong?”
That brings me to insurance companies. Regulations are a good thing sometimes. I witnessed the birth of HMOs, and how they would save the country from spiraling healthcare costs. The medical community all agreed; let’s get this under control! Then the big bad insurance companies sought to invade our town and divide the physician community by offering their plan to select groups excluding the majority, giving the contract at 80% reimbursement for exclusivity. Instead of burying our heads in the sand my medical community started our own HMO - the primary care doctors would be the gatekeepers, referring only when it was necessary. We sub-contracted administrative services with an insurance company and were successful even with the 25% price tag! We then saw the traditional competition lower their premiums to drive us out of business. The down side of free enterprise is having to swim with the sharks. After driving out the competition the premiums went back up. Why do these insurance companies have such exorbitant costs and profits? To buy office buildings on prime real estate?
Communication between medical entities was important (this was before HIPAA and electronic medical records) and as Health Officer of this small Indiana county tried to get vaccination records, done by the health department for free, to the patient’s family doctor. But guess what, the government wasn’t interested in sharing medical information. Back them I could at least get the inpatient chart if one of my patients was treated in the hospital. Now I hear the politicians talk about the greatness of the EMR, how it will improve quality of healthcare and wring their hands that physicians aren’t coming along quickly enough. The trouble I have is there is so much repetitive information that must be kept in the record the real tone of a visit and continuity of the ongoing relationship get smothered. I remember seeing my medical records from the GP who took care of me (M.E. Tomak MD) – he kept my record on a 3 by 5 note card and he did just fine by me. When I had pericarditis he actually listened to my chest and diagnosed the rub without all the fancy modern equipment, just solid diagnostic skills! Then he picked up an old-fashioned rotary phone called the big city specialist and my parents drove me to the Medical Center the same day. Physicians have finally been somewhat incentivized to purchase the software, that starts around $100K, in these days of decreasing reimbursement; but clinicians still can’t get medical records when their patients are discharged from the hospital – one step forward, two steps back.
This is the culture of elitism which has become so entrenched in our political system. Folks like Chris Matthews of MSNBC and think-tank Mensa genius guru and million dollar Democratic contributor Bill Maher openly stereotypes conservatism as racist, sexist, and stupid and then claim the prize of most tolerant, smartest and most importantly uncompromisingly correct. I guess he is pretty smart if he has that much money. The culture of elitism states that, “If everyone would just get out of the way we can solve your problems;” the problem is, for the most part, elitists like we’ve mentioned don’t produce anything, and they just rip off ideas and sell them as their own. Examples already mentioned are medication coverage and preventive care for seniors. Also they believe in a moral code of goodness without accountability, but their principles come directly from religious teachings. They forcefully will deny this last point. They want to end charities because they want a single entity, the government, to take over the entire enchilada. No more individual-to-individual, no personal connections except to “Big Brother”, no longer relying on the democratic principles of Greek philosophic roots; the elitists know what’s best for all - redistribution, socialism, elitocracy. It all boils down to power and control; since they are the best and brightest they can control how the government operates. By all means vote for progressives and we will do the rest, because we know what’s best for you.
Dateline NBC recently staged a sham where they posed as a fake pharmaceutical company looking for research sites in the U.S. and India. They proposed doing a study with a withdrawn drug, Vioxx, without giving the name of the drug and knowing that this class of drug is still on the market. After having conceptual meetings with research centers that were being courted to participate, NBC concluded that the whole drug research process is dangerous. The truth of the matter is, they were nowhere close to getting a study started without the country’s regulatory agency’s approval (i.e. the FDA in the US) – NBC was once again trying to degrade one of the safest and most effective ways to advance medical science. This is an extremely costly process because of the safety factors built in to the system. This is a drug approval system that fails five out of six times because a promising drug isn’t safe or effective enough to meet today’s standards. When I say today’s standards I reference the many generic drugs that would never get approved such as aspirin, Coumadin, many antibiotics, most seizure drugs, the list is extensive. Today’s pre-approval cost per approved new molecule is $1.2 BILLION! The media does have a story to sell but they also have a duty for objectivity. Unfortunately a bias has been built into the system.
However this form of “sophisticated” comedy has been claimed by liberals, because conservatives are much too serious to ever get it. The truth is that conservatives have reclaimed true humor. This was evident after watching Clint Eastwood’s performance during the Republican National Convention. His performance was delivered perfectly albeit from the voice of an elder statesman. There wasn’t the polish of slick shtick, but it was honest and not sarcastic. It just took a little imagination from the stupid conservatives to imagine Obama sitting in that empty chair. Nothing could be healthier in these days than to not take ourselves so seriously. Watching the righteous rancor from the likes of Andrea Mitchell and Chris Matthews was priceless. Their blinders were on considering the political targets SNL and late night TV have laughed and poked fun of – from Gerald Ford to Sarah Palin. Conservatives can’t insult the President of the United States, not when he’s an Elite!
Sadly conservatives can’t claim to like, listen, or play rock music in public either because conservatives are rich and only support the rich! I don’t think rock stars or Hollywood celebs are poor and homeless, giving all their hard-earned money away. If one were to compare the amount of money President Bush was responsible for donating to help African AIDS victims ($15 billion through PEPFAR) to say, Bono or George Clooney who do you think would win? And by the way Obama has actually reduced the funding. The latest Rolling Stone Magazine (it now costs $4.99, the f___g capitalist pigs!) featured an article savaging Paul Ryan’s musical tastes, because the theme is about rage against his kind. “His kind” is paraphrased but the article was a little prejudiced against Republicans and shame on Rolling Stone! I thought that musicians were the troubadours making all of our lives better. How many times (8 track, 33, 45, cassette, CD and DVD) do I have to buy a recording before I’m allowed to say that I listen to and love it? Listening to Quadrophenia this morning and “The Dirty Jobs” Daltrey could easily be singing about rotten employers or rotten government, “I'm getting put down, I'm getting pushed round, I'm being beaten every day. My life's fading, But things are changing, I'm not gonna sit and weep again.”
The good thing about comedy is we can all defuse negative emotions and even laugh at ourselves. The good thing about music is I can interpret it my own way. Unfortunately comedy can also be a darker force, sarcasm passing as humor. As you can probably tell I’m just as guilty. Now here comes the conspiracy theory: humor can be a weapon, a continuation of peer pressure from our school days that subliminally and forcefully makes the listener adopt the point of view of the comedian. Disagreeing with the joke is the same as “not getting it” being “square” or not being “hip.” This may be liberal elitism’s greatest secret, passing their theories as facts to the masses, with the help of televised media in a joke format. If you don’t agree you are stupid, or just don’t get it. My hypothesis is that this Lemming-like behavior is a continuation of the 60’s and represents something greater than the then-labeled generation gap. It has morphed into liberal elitism. My bias would be that a large faction of baby-boomers never got over their adolescence, too much free sex, and free drugs I guess. There were still able to get through law school with the help of their “fascist” parents’ money to create a new culture of selfishness. I am a baby boomer myself but was lucky to have been on the tail end of the whole thing.
In closing, the issues raised are based on my observations and experience; they attempt to offer a broader point of view than the sound bites on the nightly news or the myriad of comedy shows that have claim to just as many opinions that get touted as facts. Healthcare reform requires all participants to be seated at the table including the caregivers and most importantly the patients. Let’s at least hear from smokers, the morbidly obese and the homeless. We know there’s a lot of promiscuity in DC and GSA (General Services Administration) trips so let’s provide safe sex counseling to everyone getting a government job. I’ve attempted to outline a very complicated story focusing on healthcare in the U.S. Lastly, let’s all get back to work, practice healthy laughter, and have an open debate with no empty chairs to solve our healthcare and deficit crisis like Americans. We need new solutions, not rehashed, half-baked, “we’ll-read-it-after-we-pass-it” kind of solutions.