SHELL GAMES

Politics is what it is—a game of perception. It should be clear to everyone at this time that Barack Obama has little to run on going forward, and still the polls are neck-a-neck. He ran on change—transparency, Guantanamo, nixing lobbyists, unification, economic rebound, and all have failed to materialize. Arguably his biggest accomplishment, health care reform, is viewed by more than half of the electorate as a disaster in evolution. So, if you can’t run on your record, you attack your opponent’s true or perceived negatives; distraction is your ally.

Romney presents somewhat of a problem, however. While conservative opponents in the primary months attacked him as being a moderate, this won’t work for Obama’s team. Instead, they have to dredge up all the old conservative stereotypes: anti-poor, anti-women, anti-gay, pro-pollution. Among true believers, it works. Among true believers, it doesn’t matter—it’s the undecideds, the independents that have to be convinced. So they look for dirt. Here’s the challenge for the Democrat party: Romney’s been such a straight arrow that they’ve had to go all the way back to high school when he allegedly was involved in a bullying episode! Election over—Obama 1, Romney 0.

Kidding aside, if you believe character matters, a revealing story about Romney made the rounds not long ago in a paid political ad and on the Internet that has been vetted by Snopes. In 1996, when he was founder and managing partner at Bain Capital, Romney played a central role in organizing a major effort to find a partner’s daughter, going so far as to close the company and fly 50 employees to New York. He is quoted as saying at the time, “Our children are what life is all about. Everything else takes a back seat.”

Let’s look beyond the distractions to the candidates’ characters and the issues. Let’s get the divisive social issues such as abortion and gay marriage off the federal platforms and ship them back to the states, so we can focus on making the country healthy again.

The only one who wins in a shell game is the person shuffling the shells.

TUNNEL VISION

A New York Times piece by Annie Lowrey from 4/28 discussed a ray of light at the end of the health care spending tunnel, “offering some fuel for optimism about the federal government’s long-term fiscal performance.” It seems that total nationwide health care spending grew less than 4 percent per year in 2009 and 2010, “the slowest annual pace in more than five decades.”

Several factors were surmised as accounting for this: the recession, with many patients now without health insurance and others skipping medical visits due to worries about job security, the greater use of generic drugs in the wake of “a dearth of expensive, novel drugs coming onto the market,” and the shift toward accountable care, where quality rather than quantity of care is reimbursed.

Still, “[s]ome experts caution[ed] that there remains too little data to determine whether the current slowdown will become permanent, or whether it is merely a blip caused by the economy’s weakness.”

As with the general economy, I encourage readers to look past the fog of “expert” opinion and at fundamentals when deciding where we’re headed. Remember, there was a collective silence from the experts just before the economy tanked in 2008. All of the above reasons for the medical spending slowdown cited, in my opinion, are accurate. However, one of them requires ongoing economic failure for us to “succeed” in capping health care costs, the other a lack of innovative new therapies, and the third a shift to a managed care model of health care delivery (the hazards of which I’ve previously discussed). On a more positive note, the article states that many people have moved into high-deductible plans and thereby reduced their spending by 14 percent, proving once again that when the consumer is back in the loop, market corrections follow. The downside is that some of the savings were carved out of essential spending, such as that used for vaccinations, and will have health and dollar repercussions in the longer term. It should also be remembered that health care spending did increase yearly with the percent of the GDP remaining flat, at just under 18 percent.

What the “experts” may be missing is that an enormous group of aging baby-boomers are about to storm the health care citadel. In my bailiwick, I see high-cost new devices rolling out to prolong the life of the very elderly a few more years—often the very elderly with multiple other medical problems requiring expensive attention, many of whom will have limited quality of life at the end. I see murderers and sexual predators receiving costly and extraordinary care rather than palliation so we can spend more on their incarcerations for untold years to come. In short, I don’t yet see a clear societal attitude change.

We need to actually deal with these thorny issues up front. Or the tunnel will collapse before we reach the light.

SEE NO EVIL

I’ve ranted in the past that we, as a society, seem to be playing ostrich-in-the-sand when it comes to the dire state of our economic duress. Here are some more clues that we’re clueless:

A ninety-year-old patient came to the office for routine a routine follow up visit (whether nonagenarians are good candidates for specialist evaluation in this financial climate is a discussion beyond the scope of this rant). She had recently been seen in the emergency room for abdominal discomfort and constipation. The physician on duty dutifully ordered an abdominal CT which was negative. I asked the patient if an old-fashioned digital exam had been done (forgive me for those of you who are squeamish) and the answer was no. She reportedly received no effective treatment for the complaint, and the daughter cured her with an enema after they returned home. I can only imagine the hospital charges for this unproductive visit.

I recently used one of those handy “double deal” coupons to buy dinner from a barbecue place I hadn’t patronized in a long time (please don’t tell my patients). I was shocked by the rise in prices over the past few years—about 85%. The meal was barely worth the discounted price, in my estimation. Yet, they seemed busy enough, mostly with young folks. Perhaps these youthful patrons were availing themselves of the same deal, although, based on the cost of one young couple’s order relative to the coupon value, I doubt it. I wondered how all of these customers, almost certainly in a much lower tax bracket, could afford these prices.

Two seemingly unrelated events, each illuminating the same principle: We’ve moved further and further away from the common sense frugality that characterized the mindset of our Founding Fathers. In any case, I’ve seen this pattern over an over: Movie theater popcorn, a large McDonald’s Coke, pricey designer jeans with strategically placed holes. I read about the large percentage of people that haven’t put aside anything for their retirement, much less their future health care needs, and can’t help but wonder if they’re the ones standing on the daily Starbuck’s line. It often seems to me the concept of value has vanished from the American consciousness, replaced by the notion that lifestyle comes before sacrifice, and that the government safety net will always be there. Perhaps our rulers are nothing more than a reflection of this mindset.

I think it’s time we all look down and realize we’re walking a tightrope, not a path, and the safety net below is frayed and riddled with holes. And the repair crew is miles away, sipping Starbucks.

THE FOUR RULES

There have been recent reassessments of the insolvency date for Medicare. Yes, it’s even sooner than the experts thought. I can’t believe it [yawn]. Last year the predicted date moved five years forward to 2024. This year it’s 2022. So I’ve decided to present Heartheaded’s Four Inviolable Rules:

1. Don’t believe the experts. They either don’t know or have an agenda. This should have been apparent to us in 2008 when all we heard from them was a collective gasp when the bottom fell out of the economy.
2. There must and will be rationing of health care. Period. Except for prisoners and the ruling class.
3. The “right” amount of health care is an ideal and a moving target, sort of like a galloping unicorn. In camouflage.
4. In the aggregate, physician practice patterns, even among the stout of character, inevitably drift to follow the incentives, with a capital $. The moth-and-flame analogy is apropos here.

Managed care got its start in the 1980s because of concerns of out-of-control health care spending and, despite the many criticisms, did contribute to an awareness of the need for cost-conscious and cost-effective medicine, something almost totally lacking at the time. Why then do I resist its siren call and the single payer drumbeat?

Managed care is like socialism. It inevitably rewards for doing less, and encourages stagnation. It is contrary to human nature, which thrives on innovation and reward. Traditional fee-for-service is in line with these natural inclinations, and might have succeeded if allowed to function within the marketplace, but interposing third-party payers (read: insurance companies and the government) isolated the customer (i.e., patient) from costs and contributed to the mayhem. Health care, being a unique and often critical need, has been deemed too fragile to expose to the short- and intermediate-term vagaries of the marketplace, and this is not an unreasonable premise. Still, in my lifetime, insurance has morphed from a backstop to provide in times of medical catastrophe to a pay-for-all for stubbed toes and runny noses. It’s hard to say at this point to what extent the evolution of the third party payer system is responsible for encouraging the spiraling costs or exists because of them.

This brings me to the nagging question of what we can do about it. The current exploration of ACOs or accountable care organizations is an experiment in progress that is attempting to meld the current system with a managed care shell. My initial exposure to it tells me that it will be a long, tortuous process with a very uncertain outcome. So, if we must control costs but can’t do it through managed care, what are our options?

When I started this blog over two years ago I laid out the many problems in all areas of the system and suggested changes that would need to be made concurrently for any hope of success. One of those was a program to be administered by the professional societies that would provide the physician and other health care providers with personal statistics of their ordering and prescribing patterns, and their place relative to their peers. The idea behind this is that we’re the engine pulling the train—ultimately our management decisions drive the costs. Granted, there are many factors influencing these decisions, but there is still 20-30 percent waste in the system that must be excised. When presented with personal statistics, I believe well-meaning doctors (and that is the vast majority) will voluntarily change their practice patterns more in the direction of best-practice guidelines, without costly and inefficient government meddling. Physicians that aren’t “up to snuff” will also get a wake up call. Those few that are malevolent will likely change behaviors as well, fearing that the statistics will be used in a way that will ultimately have professional or criminal consequences. This approach is a way of using the medical marketplace constructively without the downside of exposing patients to potential short term financial ruin.

We can’t escape the Four Rules. But we can do a lot better job of living under them.

HOW’S UNCLE SAM?

No one likes a pessimist, a chronic doomsayer, a bearer of ill-tidings. So, with the news over the past couple of weeks of a recovering economy I risk driving you, dear reader, away, into the arms of the ever-present optimist. After all, unemployment dropped a tad, the stock market swung up (before it swung down a bit on the news of a less than anticipated increase in jobs) and the economy always bounces back, right? Even House Speaker John Boehner, a Republican no less, huffed how things, indeed, are improving (qualifying, of course, that it wasn’t fast enough, owing to Obama’s lame economic policies). Generally conservative Ben Stein admitted on Fox that the president was doing all that he could. High oil prices are, after all, determined by the world economy, not Mr. Obama.

Why can’t I see the light? Let me illustrate with a rough analogy from my experience in the medical field:

Uncle Sam is a drug addict. He’s shot up one too many times and infected his blood stream with a life-threatening illness known as sepsis and is in the intensive care unit with dangerously low blood pressure. He’s being given large doses of intravenous fluids and powerful blood pressure raising drugs we call inotropes which are effectively buoying his BP. He looks much better than when he came in. But he’s dying. He has to be kept alive long enough for antibiotics to kick in and reduce the bacterial load that is ravaging his body, and this will take about two days. However, even antibiotics are useless in the absence of an immune system that will fight the final battle to eradicate the enemy. If successful, we will be left with an intact drug addict free to inject another day, until the next battle. Sam leaves the ICU, then the hospital. He returns a year later and survives, than six months after that. This could go on forever, or so it seems. But it doesn’t, because drug addiction is terminal. Uncle Sam dies two years later from complications of his addiction.

The analogy is complete. If we substitute money for heroin; fluids and BP meds for printing money (the so-called “quantitative easing”) and borrowing; and cutting spending and revising the tax code for antibiotic therapy, you get the idea. Reducing corruption and the size of the government is analogous to stopping the addiction and bolstering the immune system. From this perspective, it’s clear that all we’re doing at the moment is treating the symptoms with fluids and inotropes—the illness be damned. In my world, this would be malpractice.

But it’s not my world. It’s the world of entrenched bureaucrats trying to buy votes to eke their way through the next election, and an electorate hoping against hope that we can make it through this ICU visit one more time.

How many more visits do you think we have left?

OUT OF CONTEXT

On February 1, Mitt Romney said he didn’t care about the poor. Of course, that’s not what he meant; he was taken out of context with a poor choice of words intended to convey the notion that safety nets for he indigent were already in place, and he was most concerned at the moment about the beleaguered middle class. His status as a multi-millionaire, however, painted a large political target on his back which his chief competitor du jour, Rick Santorum, wasted no time loosing a barb into. Romney spluttered for days trying to undo the damage.

On  March 19, Santorum, clumsily trying to underscore that his message was much bigger than one issue, said he didn’t care about the unemployment rate. The Romney campaign had its revenge, its captain proclaiming in no uncertain terms that the American public could rest assured that he, Mitt, cared. A lot.

Perhaps this illustrates why the support for the front-runner in the Republican race is, at best, lukewarm. My idea of a leader is some one who rises above the fray, the pettiness that clutters the political landscape before every election. Had Romney come forth with the statement, “I know my esteemed colleague just used a poor choice of words, as I did last month. Of course we all care about the poor and unemployed,” he would have garnered my respect. Worse than what the candidates’ behavior says about their character is what it says about their view of the American people: we’re too stupid to understand contextual speech.

Or … perchance I’m the dunce. I’ve heard many a political pundit describe how negative campaigning is very effective. Perhaps enough people follow the political process so peripherally that sound bytes taken out of context are at the heart of their decision-making. In which case the candidates, regardless of their inclinations, feel they must follow their campaign advisors’ warnings and ramp up this mindless sniping. Just once, I’d like to see a leader rise above it all, like a modern-day George Washington, and speak the truth we’d like to hear from men of honor. But George is long gone. In his place remains only a city honoring his name.

Sometimes I think he’d take it back if he could.

THE RIGHT THING

Last December a study by Dr. Arnold Epstein out of the Harvard School of Public Health published a study in the New England Journal of Medicine looking at the relationship between hospital readmission rates for congestive heart failure and rehospitalizations in general. In essence, it found that readmission rates for CHF were linked more strongly— by a large margin—to all-cause readmission rates than other factors. What does this mean? Simply put, much more than known  influencing factors (such as coexisting conditions, lower performance on discharge planning, or greater numbers of cardiovascular specialists), the “culture’ of the local medical practice patterns in terms of the willingness to hospitalize in general drove readmission rates.

More recently, a study in the journal Health Affairs reported that computerized records, intended to reduce redundant and unnecessary medical testing by providing easy access to patients’ prior tests, actually had the opposite effect. Physicians with computerized access to prior imaging ordered tests on 18% of the visits as opposed to 12.9% of the visits when the tracking technology was not available. These results apparently held true even when accounting for variables such as patient demographics, doctor specialty and physician self-referral. The reasons for this were unclear, and the data did not indicate whether the computer systems used clinical decision support that might have influenced ordering patterns.

What seems to be clear, at least to me, is that the same dynamics operate within the health care community as society at large: Medico-legal and financial incentives are hard to overcome. Rules and legislation can only do so much. The current move to realign incentives through various changes in the system, currently ACOs or accountable care organizations, are in their infancy, and my introduction to them shows them to be complex and convoluted, as systems that attempt to realign human nature often are.

Our second president, John Adams said, “Our Constitution was made only for a moral and religious people. It is wholly inadequate to the government of any other.” To paraphrase in more general terms, you can’t legislate morality or good behavior. If the medical community at large and the political forces that help shape it can get beyond the politics and adverse incentives and deal with the coming crisis as such, we will overcome it. It will all come down to four words:

Do the right thing.

SO SORRY…

About a week ago, U.S. forces burned a cache of desecrated Korans. As anyone with even a passing knowledge of world affairs knows, this would and did result in a deadly backlash, so qualifying this as a bonehead move understates the issue.

That being said, it’s unfortunate but predictable that the apologies that followed took the form they did. They traveled up the chain of command to the president himself. It did not stop the violence, and whether it even mitigated it is a debatable point. Why? Because we have chosen to willfully ignore some salient facts about the Muslim community.

First, it’s necessary to define terms. I choose to call violent jihadists Islamists rather than Muslims, because it affords clarity. By billing themselves as religious Muslims, these fanatics know they hamstring their Western enemies by cloaking themselves in the armor of religion. While Americans have become more secular and have little concern about tossing barbs in the direction of peaceful Christians (who may hunker down with their guns and bibles but rarely use the former in defense of the latter), a respect for freedom of worship still forms a cornerstone of our society. Islamists can cite a belief in Allah as the motivating force for their egregious behavior. For them, the Koran burning afforded them the opportunity to fan the flames of anti-Western sentiment and motivate their true believers into action. I suspect the leaders regarded our stupidity with glee rather than outrage. Our apology to the Muslim community was abject, and nonconfrontational. A more appropriate response from our generals and president might have been to apologize, explain the circumstances that led to the burning, promise to take appropriate action to assure no recurrence, and add in no uncertain terms that any violence on the part of radical fundamentalists would be unacceptable and dealt with in kind. However, because we expect their violent behavior even though we find it unacceptable,  and abhor senseless killing, it triggers the natural human reaction to appease. It might even be analogized to the Stockholm syndrome, where the kidnap victim begins to identify with the captor. Since the administration and much of society does not distinguish the Islamist from the Muslim, at least in the religious sense, we are, in essence, held captive.

Defining jihadists as Islamists allows us to see them clearly for what they are: a satanic cult. Allah in the context of Islamism is Satan, and all moral confusion evaporates. Islamists are Nazis using the cover of religion, and the confusion it breeds, to recruit fanatics and confound their enemies. With this distinction in place, those Muslims that don’t subscribe to Sharia law and this dark transformation of the Muslim religion can be addressed independently.

This approach has the added benefit of allowing us to more starkly define the state of the Muslim society. I stated above that we often fail to distinguish the Islamist from the Muslim in terms of their theology, and I lay this at the feet of the Muslims themselves. In my opinion, the backlash from that community has been relatively muted. There have been isolated voices of protest, but a concerted international effort on the part of Muslims has not materialized. In arguing this point with a Muslim colleague here in the U.S., the response I received was one of surprise that someone with my background could be so ill-informed and bigoted. This gentleman, who I believe to be free of anti-Semitism or anti-Christian sentiment, fears that the entire Muslim community will be whitewashed with the same negative brush and marginalized (at best) by bigotry. He was unreceptive to the argument that the outrage that would pour forth from the Christian or Jewish communities if similar acts of terrorism were committed in their names was sadly lacking from the international Muslim community. I’m proud that the incidence of violence against Muslim-Americans has been low, but I share his concerns that Muslim citizens of good character will face the specter of conscious or subconscious prejudice by association on the part of non-Muslims.

It’s exactly this association that is at the core of the problem. What remains unclear to me, and likely to many Americans, is to what extent the absence of a strident Muslim voice of protest is born of fear of reprisal or silent approbation of the jihadists’ efforts. Perhaps this uncertainty is what brands me as a bigot in my Muslim colleague’s eyes. He insists that those with radical beliefs comprise only a small percentage of the Muslim community. While I believe this to be true in this nation, I don’t know what the status is in the international community.

The bottom line is that we cannot win “the war on terror” without the active support of Muslims themselves against the Islamists. There are those that argue that the Koran sanctions the jihadists’ program of violence, and cite passages to prove their point. Although I’m not a religious scholar, in a tome as complex as the Koran with often opposing and contradictory entries, using this argument to assume we know the mind of the individual is fraught with hazard. Rather, we must judge the actions of the people.  Within the ranks of the Muslim community fear must be overcome and battle lines publicly drawn to marginalize and ultimately excise the threat, and prevent the Muslim religion from being hijacked in the service of their evil cause. Dark Islam cannot flourish in a soil poisoned to their beliefs.

Does this make me a bigot? I’ll leave you to decide. In the meantime, I’d like to say I’m sorry, but….

HOPE OR CHANGE

I’ve heard that several polls indicate that if the election were held today, Barack Obama would beat any of the Republican candidates. If true, this is compelling evidence for an electorate hungry to maintain the status quo. This seems illogical unless the majority believes one or more of the following:

• Conservatives are all evil, greedy rich people bent on accruing more wealth at the expense of the downtrodden worker.
• The president’s plan is solid and has only failed to produce results because he hasn’t gone far enough due to obstruction from the right.
• As indicated by recent statistics, the economy has begun to turn around despite the failure to balance the budget, develop a workable plan to reduce the debt or revise the current tax system.
• Government subsidies and redistribution trump concerns about debt accrual and “quantitative easing.”
• Government sponsored crony capitalism can be offset by more aggressive attempts at wealth redistribution.
• Without tight-fisted government control of the marketplace the world will be polluted or heated to extinction anyway so economic failure is a secondary concern.

I also suspect a significant proportion of the would-be Obama supporters are either marginally focused on the issues or craving normalcy to the point of engaging in wishful thinking.

A Republican president won’t guarantee success in turning this nation around. But a reelection of the current leader will be seen, with good reason, as a mandate to continue the current policies; policies which I predict will lead to a Greece-style disaster—with guns. So it’s more than an election—it’s a referendum on our dominant ideology.

While we get side-tracked with issues of contraception and abortion, it bears remembering that this is indeed the most consequential election in our lifetime. A baby conceived today will be taking its first breath at the moment in history we chart its future.

TEOTWAWKI

I’ve been watching a few episodes of a new series, a semi-documentary called “Doomsday Preppers,” about people preparing for “the end of the world as we know it.” It depresses me. Not the idea of the end as we know it (a downer if ever there was one), but the reminder of how ill-prepared I am. Experts rate the preppers on the various areas of preparedness and the majority fare pretty well. It’s not surprising, since some of them spend most of their waking hours dedicated to the task and have thousands of dollars of stored foodstuffs, much of which they’ve raised/canned themselves, enough to feed as much as a dozen hungry mouths for over five years. I have a peanut butter and jelly sandwich in Saran wrap in the freezer.

All right, we’ve put away a small stash of canned goods and emergency water. We’re not off the grid and, at this time, not on the fast track to getting there. I started reading James Wesley Rawles’ How to Survive the End of the World as We Know It and after getting though about fifteen percent of the book, demoralized by my lack of preparation and skills, filed it under “reference.” As if a digital book and a Kindle will be of any use at the end of the world as we know it. You can see what I’m up against.

But I’m not alone. Although a growing number of us recognize the wisdom of preparedness, most people still regard preppers as a fringe element. Until a couple of years ago I was among them. A few things changed my mind. Foremost, as anyone who has read my prior rants knows, is the sorry state of the economy. While this plays big in the motivation of some of the TV preppers, others cite fears of global oil shortage, an electromagnetic pulse from the sun destroying the world’s electrical grids, or even the sudden reversal of the Earth’s magnetic poles and its attendant tectonic shifts (an every 500,000 year event).

Regardless of the motivation, some attention to emergency preparedness seems to me to be a no-brainer. There is precedent for this line of reasoning: With limited evidence for global warming that has created a hypothesis that is widely regarded as fact (in the 1970s it was global cooling), people are willing to accept this as an impetus to change our behavior. Even if the evidence is flawed, the move toward a less polluted environment is laudable (except when used as a smokescreen for a (usually socialist) political agenda). The same can be said of preparing for TEOTWAWKI. In the event of an earthquake, hurricane, tornado, or massive conflagraton, assistance and law enforcement may be sidelined for days, or weeks. The more global natural disasters referenced above are admittedly less likely, but taken together may be worth a nod as well. Economic collapse, on the other hand, may have up to a fifty percent chance of realization. Why do I say this? If we’re five to ten years behind Greece, as some experts think, and we fail to change our debt-first, common sense last approach to financial management, who will be there to bail us out? The supply lines in the cities are fragile, and most wealth is digital, a scenario ripe for disaster. A failing European economy and fragile oil pipeline in the Middle East due to political instability could theoretically trigger a slide even sooner. Or a war instigated by Iran. This, to me, seems to be a more imminent threat than global warming.

The truth is, it’s easier for the political class to decry global warming because it’s more distant, seemingly more manageable, and carries with it an aura of nobility. Focusing on the more proximate threat of global bankruptcy highlights their greed, incompetence, and impotence. From the standpoint of the American people, it’s a topic that is perhaps too alarming to face head on.

Is financial Armageddon inevitable? I think we have a window of several years to turn it around. I don’t know if we have the will. I believe the upcoming election is a barometer of that will. If more than half the country feels that leaving the current leadership in place is the answer, it speaks to the ascendancy of an ideology based on equality and parity of ownership (read: wealth redistribution), and to the decline of the principles on which this nation was founded: freedom and parity of opportunity. We’ll have moved from a democratic republic to a democracy, one that has elected social justice over liberty. This will not be self-sustaining.

If the current “management” is thrown out, there is no guarantee of success (spouting an ideology of reduced spending and small government while doing the opposite is the hypocrisy of the right). However, if the majority votes for change and doubles down on it, there is at least a chance it can become reality.

That’s TEOTWAWKI I can live with.