The answer is the Medicaid expansion.  This is the biggest and most significant expansion of government health care in the last several decades. Traditional Medicaid covers children, pregnant women, and people under the age of 65 with significantly disabling chronic illnesses such as multiple sclerosis. However, under the ACA, up to 20-30 million additional Americans will be able to get government health care coverage without the need for a disability. They only need to be poor. This is a far more significant development than the individual mandate even though the mandate gets all the legal attention. It’s significant as a potential for a funding disaster and there is recent precedent to support this.

In 1994 Tennessee decided to dramatically expand its Medicaid coverage (called TennCare) to include 500,000 people who were previously uninsured either due to poverty or preexisting illnesses. Ultimately up to 1.6 million became enrolled in TennCare  and subsequently the total annual budget for this expansion went from $2.64 billion in 1994 to more than $8.5 billion in 2005 which far exceeds national health care cost inflation over this same time period. With fiscal predictions that TennCare would eventually take up 90% of the state of Tennessee’s entire budget, massive cuts in enrollment and funding were undertaken amid a storm of protests and lawsuits.

The reason TennCare failed was because it provided generous benefits without much in the way of controls or limits on excessive utilization. The original TennCare program was all inclusive. It paid for everything from dental care to mental health and substance abuse treatment, to all prescription medications, to basic outpatient, and preventive care.  Ironically, managed care mechanisms built into the original program soon collapsed due to TennCare’s low reimbursement rates. ERs stopped bothering to get authorization from doctors to see patients during office hours and managed care companies dropped out after losing money.

To be even more specific, the reason TennCare failed was that, like Medicare and traditional Medicaid, TennCare is not an insurance program. It’s a entitlement spending program by virtue of its generous benefits. It provides financial resources to spend on health care needs both big and small. It’s not as if hundreds of thousands of Tennesseans suddenly became seriously ill. But many were provided funding for every health milady. Instead of taking over-the-counter medications for minor conditions such as chronic arthritis or seasonal colds and influenza infections, TennCare beneficiaries could now visit a medical doctor and receive prescriptions whether it made any difference or not.  TennCare became the equivalent of a government subsidized auto insurance policy that paid 90% of the costs of gas, oil, regular maintenance, cleaning, and minor repairs.

The sad but “convenient” truth is that the uninsured are relatively inexpensive.  As I have stated before, contrary to popular belief the uninsured do NOT flood emergency rooms because they can’t get medical care elsewhere. They are their own best managed care system by avoiding expensive health care except for serious conditions. They have what is effectively an unlimited deductible. The biggest problem with an uninsured population is cost shifting. Uninsured people who do get seriously ill and need health care will get it. Federal law prevents hospitals from turning away patients with unstable medical conditions regardless of their ability to pay. Many of these will become eligible for Medicaid otherwise the costs of their care are “shifted” to the rest of us in the form of higher costs and taxes. Even with cost-shifting however, the overall health care costs of the total uninsured population remain relatively low. For example, in 2008, the uninsured spent $30 Billion in out-of-pocket care and $56 Billion in uncompensated care (usually due to serious injury or illness) of which various government programs eventually covered 75%.

Most cost shifting occurs because of serious illnesses; accidents, heart disease, malignancy, or chronic neuromuscular diseases that lead to hospitalization and/or the need for expensive long term care. If the Medicaid expansion were an actual government subsidized and supported insurance program then it would only provide coverage for serious illness and expensive unanticipated health care needs in much the same way that low cost, high deductible private catastrophic health care insurance does. However, like TennCare the ACA has decided to opt for health care egalitarianism and move towards all inclusive care no matter the need . . or the eventual cost. Using the numbers from TennCare as a guide, the Medicaid expansion may cost $105 to almost $160 BILLION per year to fund an additional 20-30 million Medicaid beneficiaries and this is on top of the current annual budget of almost 300 Billion. And keep in mind, this is BILLIONS to pay for the health care costs of people who are relatively healthy. They’re just poor.

What about the individual mandate? The Department of Health and Human Services (HHS) has stated that private insurance plans offered to individuals or through health exchanges must provide coverage of up to ten general categories including prescription medications, mental health and substance use disorder services, wellness care, etc. Once again, this sounds more like forced health care egalitarianism than a realistic insurance package. Though there is nothing in the HHS rules that specifically forbids the offering of high deductible health care plans (aka, catastrophic health care plans), these types of low premium plans may not qualify due to the fact that much of the initial costs will be out of pocket. But if  high deductible plans do qualify to meet the individual mandate requirements then it is plausible that most relatively healthy individuals will rationally choose to purchase these lower cost plans. Regardless, many who would otherwise be able to afford a low cost high deductible plan will be eligible for government subsidies to purchase a more expensive all inclusive plan.

Voltaire knew about bullshit 300 years before the ACA

The benefit of mandated egalitarianism is that the relatively healthy population is forced to purchase a high cost health care plan that they don’t need in order to offset the health care of the small minority who are responsible for the majority of the costs.  This already happens in the private insurance market where healthy individuals and families purchase expensive all inclusive plans when an HSA plan or high deductible plan would suffice.  These high cost plans are expensive in part to cover the costs of the sicker and more expensive members of these plans. The claim that the costs of the uninsured are directly responsible for increased private insurance premiums is dubious at best since – as mentioned above – the vast majority of the health care costs of the uninsured either come out of pocket or are paid by the government. And now that insurers can no longer deny coverage to those with preexisting illnesses, the premiums of all inclusive plans are unlikely to go down any time soon.

Lastly, there is the basic economic effect of inflation whenever large amounts of money are infused into the system. Fundamentally, the ACA is a massive spending law with a few insurance reforms thrown in for good measure and it will infuse hundreds of Billions of dollars per year in additional government spending into the health care and insurance industries. Since our Federal government already spends far more than it takes in, this additional funding will be in the form of deficit spending. Essentially the government will be printing new money backed by foreign loans it has no intention of paying off anytime soon. Whenever there is an artificial infusion of money into a system the prices of  affected goods and services goes up dramatically. This effect is commonly seen in gold rushes or other proliferation of natural resources on local economies. Without any logical or effective mechanisms to control costs or utilization of health care resources, the ACA is setting us up for an even bigger spike in health care costs.

Expanding affordable health care access to all Americans is a very laudable goal. There are logical and rational ways to go about this . . . . and then there is the Affordable Care Act. It assumes that one health care plan fits all. It infuses Billions in funding on relatively healthy populations with the goal of getting as close to universal coverage as possible without stopping to ponder the actual needs of the very people it covers. It has very little in the way of mechanisms to control costs and prevent excessive utilization because it assumes that 100% of all health care needs are legitimate and that beneficiaries are idealistic liberals who will not  abuse any entitlement program as important as health care.

Like Voltare’s famous paradoxical affirmation that the Holy Roman Empire was neither holy, nor Roman, nor an empire, the Affordable Care Act is likely to prove itself to be anything but affordable.

But it is fun and interesting to see how people adhere to certain segments of a two thousand year old document and completely and conveniently ignore other parts . A case in point is Deuteronomy 22:28-29, to wit,

“If a man happens to meet a virgin who is not pledged to be married and rapes her and they are discovered, he shall pay her father fifty shekelsof silver. He must marry the young woman, for he has violated her. He can never divorce her as long as he lives.”

Not only are you unlikely to ever see this biblical verse in numerical form under the eyes of Tim Tebow, but you are unlikely to see the GOP advocating for this biblical law as an inclusion to any state sexual crimes statues.

BUT,

Of course the same literalists will be opposed to a woman’s right to chose and a homosexual couple’s right to be protected by the same civil laws that apply to heterosexual couples based on . . . . . . biblical literalism because the Bible is supposed to be the word of God.

“The word”? It gets very interesting when you analyze the idiosyncrasies that arise in many verses. Deuteronomy 22:28-29 specifically states that a man should marry his rape victim and pay 50 shekels of silver only if they are discovered!

Seriously?

Correct me if I’m wrong but isn’t GOD, by definition, supposed to be all knowing? And if she is, then why include such a qualifying statement to an obvious rape-and-punishment edict? The answer should be that Deuteronomy was originally part of a basic local civil justice code for nomadic desert people from two thousand years ago that should not necessarily apply to modern life.

The next time that someone advocates against civil rights for same sex couples, ask them if they also would require that rapists marry their victims? Obviously only if they were discovered.

(Found per Reddit)

And this makes liberals mad. So mad that they want the investment income of multimillionaires to  be taxed at the same higher rate that many working Americans pay. Fair enough. But this still doesn’t change the fact that millionaires like Mitt and Warren don’t have to lift a finger in order to make millions. Inequality still exists! Perhaps in addition to a higher tax rate, members of the non-working 1% should be forced to perform a set amount of labor, maybe for charity? Mr. Buffett could give out free individual investment advise and Governor Romney could . . . . . do whatever he does.

Why not? After all, many physicians are regularly forced by the Federal government  to perform thousands of dollars per year in non-reimbursed charity care while being specifically prevented from claiming a loss for such care on their taxes. The scam works like this. The Federal government requires (EMTALA) all full service hospitals that accept Medicare and Medicaid to “treat and medically stabilize” any patient who presents to their emergency room regardless of their ability to pay. Because the Federal government has never effectively defined the condition of being “medically stable”,  patients usually undergo the full gambit of tests and treatments as appropriate for their condition regardless of their ability to pay. The cost of this care is often in the range of tens of thousands of dollars per hospitalization and is often beyond the financial ability of a patient who was unable to afford the cost of health care insurance in the first place. Hence, much of the cost of this care goes unpaid.

A business that loses income from a customer’s inability to pay is often able to claim a tax deduction as a business loss. In order to claim this deduction, the business must show that it incurred a net loss from providing services or products without receiving reimbursement.  However, this only applies to business expenses and not individual effort. A hospital based physician who saw and cared for a patient who never paid for these services cannot claim a deduction on his or her taxes because the physician’s business never lost any money. It is the hospital that will be able to claim a deduction on its business taxes since the care received is a service that consumed supplies, a room, and the time and effort of hospital employees who then must be paid.

As a hospital based physician I earn only what I can bill insurances and the occasional uninsured patient who pays out of pocket. In the course of a year I guesstimate that I perform $40 to $90 thousand in uncompensated care for uninsured patients admitted through the ER as required by Federal law. This is not chump change. This represents not only an extensive amount of my time and effort as well as my expertise earned from prolonged and intensive medical training but the legal liability of a doctor patient relationship for which the non-paying patient retains full legal rights to sue me for any reason.

But it’s not charity care that angers me. I would much rather have a “treat first” and worry about the billing later policy and many of these uninsured patients are in dire need of care. What angers me is that fact that I feel “forced” to work for free by the laws of the same Federal government that won’t give me so much as a pat on the ass and a “good job” before taxing the rest of my income at a rate higher than Mitt Romney’s. I’m not lucky enough to be able to earn thousands of dollars from investments while sitting on the toilet reading the Wall Street Journal. Every cent I earn is from actual work.

If the liberals can complain about unequal tax rates for millionaires then I can complain about uncompensated labor forced by the Federal government. It’s time that physicians receive an individual tax break for uncompensated care performed under Federal EMTALA laws.

The glaring contrast was between employees with different education and training background – and incomes. Physicians, advanced nurse practitioners, and certified nurse anesthetists all seemed to have a far lower rate of absenteeism due to illness than those with less education and training. Even the mid level management and department heads had higher rates of sick leave.  Why?

Does it have to do with getting paid for sick leave? Workers with more training and benefits – those in government jobs especially – are more likely to receive paid time off than unskilled workers. What about income?  Are you more likely to come to work if you make more money? The answer is yes but the reasons are complex. High income means more money lost for unpaid absenteeism (health care providers usually do not have PTO benefits) and a sense of obligation to work harder as a return on what they see as a “gift” from their employer (gift-exchange model).

To be more specific, higher paid workers tend to have more education and training which inversely correlates with absenteeism.

Research by Koopmanschap et al. (1993) found that lower educational levels correlate with a higher risk of becoming disabled. A recent study appearing in the BMJ-Open delved even further into this issue by examining the correlation between innate childhood intelligence and the long term risk of becoming disabled with chronic medical problems. The results were dramatic. Of children tested in 1946, almost 50% of those in the bottom quartile of cognitive ability ended up on long term sick leave compared with only 13% of the top quartile performers. These differences decreased over time as social status became less of a barrier to educational opportunities but significant differences remained.

It’s not clear why intelligence and educational levels correlate like this. Contrary to popular belief, it is not necessarily because of unhealthy lifestyle differences among groups of different education levels.  For example, obesity rates do not correlate well with education or income level. I have known plenty of doctors who are overweight and smoke and substance abuse rates among doctors do not appear to be much different than the population at large.

Rather then being a case of more people with lower educational levels making worse lifestyle choices than those with more education and higher incomes, it’s more likely that people of lower socioeconomic status have far less ability to absorb and to rebound from the negative consequences of harmful lifestyle choices than those with higher education levels and/or more financial resources.

And they might be less likely to appreciate the near and long term consequences that poor health choices have on their overall health and ability to work. The frequent absenteeism among employees with lower rates of education and training are likely a harbinger of a higher risk of developing permanent disability and illnesses. There is not any good data on this phenomenon but the risk is certainly there. In the end, it is simply and relatively easier to go on disability than to continue to work at an unskilled and low paying job while in poor health and in chronic pain.

What the internet looked like in the '80s and what electronic medical records look like today.

The Internet beta 0.5 version was nothing like it is today.  Back in the ’80s and the early ’90s the most common way to access the outside world was to use a phone modem to dial the number of a remote computer. These primitive servers usually ran DOS based software called a Bulletin Board System (BBS) which allowed users to post messages to each other. For the most part, these servers were isolated and did not communicate directly with each other. If you wanted to connect to a different BBS you literally had to hang up on one and call another one. There were usually no centralized servers that could link and share information among multiple BBSs. This sharing of information among multiple interconnected computers, servers, and networks is essentially what the modern internet is and once the world wide web started to proliferate in the mid to late ’90s the old BBSs became extinct. Facebook is a perfect example of modern Internet use. It’s essentially a vast central database with millions of users who can easily access information using multiple devices, upload and download data in multiple formats (text, links, pictures, video) from multiple sources and all from a single internet connection.

It sounds like Facebook would make a great starting template for a vast interconnected medical records system. But the reality is that the electronic medical record (EMR) industry is still stuck in the era of the BBS.

The similarities between modern EMRs and the BBS system are striking. Like many old Bulletin Board Systems the vast majority of EMR systems do not communicate with each other (nor even the outside world). Not only are they often incapable of communicating with another EMR or computer but even in 2012 most new EMRs don’t even have an option for sharing information with other systems! This is one of the biggest paradoxes and failures of almost all EMRs. Designed for an industry where the sharing of medical information among different facilities and health care providers is critical to the timely, effective, and safe delivery of medical care, the majority of these systems are designed to share information only within the limited confines of the specific facility or health care system that they serve. EMRs are essentially information islands cut off almost completely from direct contact with the rest of the interconnected world.

The system at the hospital where I work is a perfect example of this isolationist mentality.  In its current form, the hospital EMR cannot send or receive information from doctor’s offices, labs, or imaging centers outside of the actual facility. Acquiring old documentation still requires one or more phone calls, several human intermediates, a fax machine (40 year old technology) and open business hours (no luck if after office hours, on weekends, or holidays). Even worse is that the system can’t even communicate with older electronic systems within the same facility and has no capability to input and store faxes or scans in a format such as PDF for internal viewing. This means that we are still stuck with a hybrid EMR-paper chart system that is often more cumbersome and inefficient than using either system alone.

And how did it get to this pathetic point where a guy in rural Brazil can upload a picture of his strange rash to someone in China in real time but I can’t get critical medical information on a patient found unconscious until their doctor’s office opens the next business day? Given all of the concern about online privacy and hacked Facebook accounts you might think that the health care industry is cautiously avoiding systems where private information could be compromised (never mind that there has not been a massive collapse of the credit markets from widespread identity theft and fraud from 100s of million of Facebook users). The motivation of the health care industry in avoiding interconnected medical record systems is not to protect patients but rather, to protect itself.

Specifically, they want to protect themselves from competition. The majority of health care facilities and health care providers still think about medical records the same way they did 100 years ago – as property or proprietary information. A physical medical chart is considered to be the property of the facility or provider who generated the chart even though the patient is considered to be the “owner” of the information contained within the chart. A Paper chart is usually stored at the same facility where it was created and patients often prefer to return to the same facility or provider if for no other reason then because “that’s where my records are.” Changing facilities or providers can often be a problem for patients who must go through the bureaucratic hassles of making a formal request for their records and then having to pick them up and hand-deliver them to a new office or provider. This system is effectively a disincentive for patients who wish to change providers or health care facilities and is, ironically, a barrier to the sharing of information.

Not surprisingly, the electronic version of the medical record system continues this same isolationist mentality. Even though digital information replaces paper folders and charts, electronic records are usually restricted to the system that generated them. Most EMRs are designed to be run on a server or computer that physically exists within the same office or facility and without any direct connection to the outside world. The only way to share information is the old fashioned way – i.e. the electronic record must be printed out and either faxed or hand-delivered to another office or facility. In this way, most EMRs are little more than a hard drive replacing a filing cabinet. But wait, that’s not all. Most EMRs are themselves proprietary software. Most of the expensive systems in particular are not compatible with transferring information to other EMRs without extensive and expensive modifications. If all EMRs could communicate with each other equally then providers would just purchase the cheapest ones thus damaging the finances of the industry. Right?

Wrong. Business is ripe with examples where standardization and compatibility among different products has lead to expanded market size and share even among competitors. The electronics industry is just one example. Another example is the Internet and web browsers. If Internet Explorer were only able to access web sites running Windows server software, then the massive growth and success of the Internet would have been severely blunted. Instead, the industry got together and decided on a common language (HTML) that is usable by any browser. Obviously industry standards can be voluntary or by government mandate. So the question is; why not make all EMRs capable of communicating and sharing information with each other? The Federal government recently had the chance to do so and severely blew it.

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provided financial incentives for early adopters of electronic health records and even provided definitions of “meaningful use” and what information an EMR should be able to record and store. But the single biggest failure of HITECH was that it did not define standards of compatibility nor even require compatibility among any of the thousands of different electronic medical record systems. Hundreds of millions if not billions of tax dollars will now go towards further entrenchment of the current isolationist proprietary EMR industry.  And this is not good for patients or consumers either. In theory, if all electronic medical records were freely and easily transferable among different providers and facilities, the artificial barriers for patients to changing providers and facilities wound be gone and providers and facilities would have to compete based solely on the quality and efficiency of their services rather then relying on holding medical records hostage in order to generate return business.

However, improved competition among health care providers is not the primary aim of open and efficient transfer of health related information. Accurate and up to date health care records that are easily and universally accessible have the potential to improve the safety, quality, and efficiency of health care delivery. Costs can be decreased by reducing the need for repeat labs and tests. Older patients in particular would benefit from accurate medication lists and lists of prior drug reactions and allergies to reduce the possibility that providers will prescribe medications that could interact with a patient’s other medications or be contraindicated for any one of their medical conditions.  Ensuring that open and free communication of medical information exists between EMRs appears to be beyond the scope of the current records industry. This is something that only the Federal government will be able to do when and if it decides to get serious about modernizing health informatics.

Usually, alprazolam is prescribed as a short term treatment of acute anxiety disorders. It is classified in the US as a controlled substance with significant abuse and addictive potential. It’s popularity may be due in part because it is widely considered to be relatively mild and safe by many patients and their physicians. But, in fact, alprazolam can be much more toxic than even other prescription sedatives.

However, unintentional overdose with alprazolam alone is unusual (it was responsible for less than a quarter of ER visits  for benzodiazepine toxicity in the US for 2008). What is much more common is unintentional overdoses that involve other prescription medication and/or alcohol. It’s unclear why but it may be that patients are unaware of or tend to minimize the risks of combining different controlled medications that could suppress breathing. Or they don’t realize that alcohol can suppress breathing, be difficult to dose (because you are already intoxicated), and have an additive effect when combined with benzodiazepines.

What I want to know is . . . . who is the physician . . . .  being aware of Mrs. Houston’s very well publicized problems with substance abuse, including cocaine and alcohol . . that he or she felt compelled to write her a prescription for alprazolam or other sedatives which she then reportedly filled at a local pharmacy? It would have been understandable if the late Mrs Houston had diverted another person’s medications for her own use or acquired sedatives over the internet or in another country or illegally on the “street” but from all accounts she was actually legally prescribed these medications by an American physician!

Strictly speaking, a history of alcohol or other type of substance abuse is not a legal or medical contraindication to prescribing controlled medications for a medically valid reason. But, there has to be a good degree of due diligence and caution on the part of the prescribing physician in these cases.  Drug testing can be done on potential candidates for therapy with sedatives and a detailed and complete history of the patient’s prior problems with substance about should be performed in order to allow the physician to get the best possible idea of the patient’s tendencies and potential for abuse. Treatments for pain, anxiety, and insomnia should start with non-controlled medications and drugs with the lowest potential for harm and abuse before stepping up to more powerful alternatives. In the very least, small amounts of potentially harmful medications should be prescribed in a “trial” treatment period to be used sparingly and only as a last resort.

But this approach is often an idealistic fantasy when confronted with the reality of real-world medical practice. Patients can be demanding and incredibly impatient and the physician has only 15 minutes (often less) to gather as much information as possible and develop a complex treatment plan. Too frequently this process gets degraded into the best plan for getting the patient in and out of the office in the shortest amount of time and this often includes a month’s supply of the desired medication and a cursory warning of the risks.

But even without these time constraints, the fact that the patient is a major celebrity can have significant and deleterious effects on clinical decision making. This was clearly seen when Dr. Murry felt compelled to discard sound medical judgement when he delivered a powerful anesthetic to Michael Jackson to treat insomnia. Maybe this is what happened in the case of Mrs. Houston? How can you say “no” to a famous patient?  The temptation to give in to the needs of a super-famous client might have been too much for the local MD.

Still . . . . . this justifies nothing.

Americans invented the idea of  “McDonaldization” in which consumer services are standardized to be efficient, predictable, and controllable.  When we want something, we want it now!  We want to be able to understand it, predict it, and control it.  However, healthcare isn’t a service that’s amendable to McDonaldization.  Cooking and serving up fast food has a relative small number of variables that can easily be controlled and predicted such as the size of the hamburger patty and the heat and time required to cook it. The diagnosis and treatment of human illness has literally hundreds of millions of variables to deal with. This is why medical care is not anywhere near as “convenient” as fast food.

But the folks at X-prize want to change this.  Their solution is to open a competition for inventors to develop a Star Trek style “tricorder” to detect and diagnose disease just as the fictional medical tricorder was used in the science fiction series. What is the specific problem to their tricorder solution? According to their promotional video, consumers are faced with a paradox.  From the video;

You want to know what’s wrong. Is this normal?  Is this urgent?  Do I need to see a doctor? But, today, the only way to know if you need to see a doctor is . . . to see a doctor. And that’s not fast, not convenient, not easy. So you wait . . .

The average time to get an appointment is 21 days. The average visit to the doctor takes nearly 2 hours.  Cause you’ve got nothing better to do, right? And then you only receive the right diagnosis or treatment 55% of the time.

Correct. Medical care is nether efficient, convenient, predictable, or controllable and this drives Americans crazy. Part of the reason is the massive complexity of human disease. Part of the reason is how our health care system is organized with way too much emphasis on advanced medical care and procedures and too little emphasis on health care access, primary care, and prevention.

The X-prize foundation’s approach to this problem is to empower consumers and patients with a quick and easy home or outpatient mobile  device to provide real time data on critical health metrics such as vital signs to accurately diagnose disease.  The requirements appear to be only that the device is mobile and be able to accurately diagnose a set of 15 diseases. There is no information on what these “diseases” would be.  The device should also be able to give information to the patient as to whether everything is “OK” or not.

The push to develop a more patient friendly health monitoring device is certainly laudable.  However, it’s not likely that such a device will work in the way that they intend it to. The problem won’t necessarily be with limitations in technology. The problem will be in how we interpret and act on information. The limitations and complexities of the diagnostic and treatment process is something that doctors have to deal with every day. Doctors take a limited set of data and formulate what they believe is the best diagnostic and therapeutic course of action that is uniquely tailored to each patient and each  situation.  They take into account not only the data but their training, experiences, statistical probabilities, and “educated guessing”. This is why medicine is still an art.

And data is not the end point of the diagnostic process. Each abnormal data point could have multiple meanings depending on what you are looking for (the pre-test probability) and the statistical likelihood of disease in your particular population. For example, an elevated blood pressure could mean that you have hypertension or it could mean that you are anxious or because of medications or because of renal artery stenosis. A high heart rate could mean anxiety or a pulmonary embolism. Abnormal laboratory results have the same problem. A low sodium level could be caused by anxiety or a brain tumor. Anemia could be caused by a poor diet or colon cancer. Even imaging is tricky. A mass seen on an XRay or CAT scan could be benign or malignant. There is even the fixed and known possibility of false positives and false negatives for each test that has nothing to do with error or technical variability. Detecting abnormalities is easy. It’s the interpretation that is hard. To say with confidence that your device will be able to diagnose a specific disease with “accuracy” is dangerous thinking.

And who or what will interpret the data for the tricorder user? A computer algorithm can be used but is likely to come up with a diagnostic differential list that may not be accurate and will certainly not be exhaustive. This is because the initial evaluation of a patient is often followed up by more advanced evaluation and it is currently not possible to put every diagnostic modality (Xray, CT scan, PET scan, nuclear imaging, EKG, EEG, biopsy, stress testing, and exploratory surgery) into a mobile phone. Maybe in the far future we will develop a “universal” diagnostic device that includes everything but this is not one of the stated goals of this X-prize.

Even worse than diagnostic uncertainty is the false sense of security that could be provided by normal data in the setting or real disease (i.e. a false negative). The FAQ page from the X-prize foundation states that the tricorder should be able to “give confirmation that everything is ok with a consumer and notify that something is not ok (a “check engine light”)“. This approach is simplistic and absurd to the extreme. Show me a person with completely normal vital signs and blood tests and I’ll show you a patient who is has undiagnosed HIV or a smoker who has a malignant growth in their lung. The danger is that whatever limited data this device does provide will, if normal, give consumers a false sense of security and lead them to cancel that trip to the doctor.

The biggest problem is that such a device is either not required for it’s intended purpose or won’t make any difference in outcomes. Will it really be able to help people make a decision on whether or not to see a doctor or go to an ER? True medical emergencies almost never present subtlety. Ironically, PAIN is one of the biggest indicators that something is seriously wrong and the measurement of pain is not something that can currently be directly done by a tricorder or any other device.  Bleeding, passing out, shortness of breath, vomiting, decreased consciousness; patients rarely have a problem knowing when something is seriously wrong because their bodies do a much better job than any tricorder could do in letting them know. And when should you go to see a doctor in an non-emergent setting? The best way is to use a simple rule of thumb. If you have to consider it then likely you should go. And as far as prevention, do we really need a device to tell us to stop smoking, loose weight, and get some exercise?

There yet may be some uses for such a device. More frequent monitoring of metrics like blood pressure and blood glucose levels in the outpatient setting may, if accurate, help doctors to better control such chronic conditions as hypertension and diabetes and better control can lead to better outcomes. Cheaper and mobile medical devices would help health care workers enormously in areas of the world that are remote and/or lack access to modern medical care.

But to develop a device with the stated goal of “empowering” consumers in their health care decisions by helping them know when they can avoid the inconvenience of having to see a doctor is amazingly shortsighted and ridiculous. And it’s potentially dangerous by giving people a false sense of security that they do not need to see a doctor.

I foresee one main outcome of the development of this tricorder. The typical civilian users of such a device are likely to be suburban, middle aged, relatively healthy and health obsessed. These are the types of patients that doctors in affluent areas dread. These patients Google the differential diagnosis for every single symptom or strange noise coming from their bodies and make frequent trips to their doctor with pages of printouts about their “condition”.  Congratulations X-prize! You’ve begun the process to develop the most important enabler for hypochondriacs that the world has ever known.

It’s stunning to think about the national debt in these terms.  What’s even more stunning is how brazenly both parties, liberals, and conservatives are willing to risk long term economic security to feed their own ideological interests.  A case in point is the NYT’s Paul Krugman who dismisses any short or long term concerns about the US debt with a fanciful wave of his a priori wand. What is Dr. Krugman’s calming tonic in the face of a 15 Trillion dollar IOU? Basically, he implies that the debt doesn’t matter as long as you can raise taxes and interest rates remain low.

Deficit-worriers portray a future in which we’re impoverished by the need to pay back money we’ve been borrowing. They see America as being like a family that took out too large a mortgage, and will have a hard time making the monthly payments . .

First, families have to pay back their debt. Governments don’t — all they need to do is ensure that debt grows more slowly than their tax base. The debt from World War II was never repaid; it just became increasingly irrelevant as the U.S. economy grew, and with it the income subject to taxation.

So as long as we have rich Americans from which the US government can feed from then we will be OK. After all, the top 5% of income earners pay 60% of the US income tax even though their income is 35% of all personal income. For liberals, as long as we can raise taxes, we can continue deficit spending ad nauseum.  For conservatives, it’s even worse. The mantra appears to be deficit spending with low taxes now (trickle down) and to hell with the future.

Of course, Krugman is correct . . . .  about the present. The enormous US debt does not pose a serious short term threat to the stability of the US economy or economic recovery.  Given the sheer size of the US economy, there is no credible risk that the US government would default on it’s debt nor is there any reason to believe that the market for US Treasury bonds would dry up or become unstable. And interest rates are at an all time low, thanks mostly to the severity of the recent recession and the efforts of the Federal Reserve to stimulate the economy through borrowing and investment.

But, like the sky diver falling without a parachute, the danger for the US economy lies not in the present while tumbling through space but at some point in the future when the ground makes its presence known. It’s inevitable that the economy will pick up steam and with growth will come a rise in interest rates. Even small increases in rates can have a profound impact on the interest we pay on the debt.  Right now the interest payment on the national debt is about $242 billion a year.  Interest rate increases over the next decade have the capability of causing the interest on the national debt to exceed $1 TRILLION a year! Chew on this number for a while. This amount represents mandatory spending that does not go towards any social program, military asset, or regulatory agency. These billions pay investors in the US debt of which almost 50% are now foreigners (mostly the central banks of China, Japan, the United Kingdom and Brazil).

There is a very real possibility of a spiraling and out of control situation to develop as the interest on the national debt becomes bigger. Growing entitlement programs (Social Security, Medicare, Medicaid) combined with the increased interest payments could cause mandatory spending to exceed total government revenue. At this point the government’s ability to manage the debt would become even more difficult from a budgetary and political standpoint. The remaining choices, massive cuts in discretionary spending (including defense), massive cuts in entitlement benefits, and/or massive tax increases would become ever more drastic and unpopular.  Just like today there would be government gridlock, indecision, and political pettiness all resulting in  action that will be too little, too late. Meanwhile, the spiral continues, with increased budget deficits creating an ever larger national debt with increased interest payments

What happens then? The problem is that nobody really knows, not even Dr. Krugman. There is a great amount of debate among economists about how big the national debt burden could become and when the economy would become negatively affected. There is evidence that among industrialized countries, those with national debt below 60% of GDP had better annual economic growth (3-4%) than those with debts of 90% or more of GDP (1.6%). Though it’s unclear whether the larger debts were due to a slower economy and a decrease in tax revenues, the possibility remains for a negative impact on economic growth. Krugman further tries to differentiate debt held by households from the national debt.

This is the point almost nobody seems to get — an over-borrowed family owes money to someone else; U.S. debt is, to a large extent, money we owe to ourselves.

No it’s not.  As mentioned, almost 50% of our debt is held by foreign banks. And we can’t just stop paying interest on the debt because it’s “money that we owe ourselves.”  A US default on its debt or even a perceived inability of the US government to pay interest on the debt would result in volatility in the bond market causing falling bond prices and increased interest rates which would worsen the budget crunch as previously stated.  The US government is very much like a household that is very overextended on its credit. It’s like a family taking advantage of a credit card with no limit and ridiculously low interest rates.  A default would wreck the world wide economy and impair the government’s ability to borrow more money at low interest rates.

But lets assume that Krugman is correct and we can go on borrowing forever because it’s money that we owe ourselves that we don’t have to pay back. The problem with this “all is well” approach is it does not take into account the possibility of a “perfect storm” of different economic factors combining with our debt burden to result in economic catastrophe. Greece is a good example. They were forced by the Economic Union to adopt the Euro at inflated exchange rates for the old drachma that severely impaired their ability to borrow and service their national debt.  Though the US does not face the same type of monetary problems, the recent collapse of the sub-prime lending market is a good example of an entirely new economic variable that was unforeseen by almost every economist.  Hence, like earthquakes, economic disasters are very hard to predict but inevitable. The US national debt is like the proverbial sword of Damocles hanging over our heads. It has the potential to dramatically worsen and complicate what would normally be a survivable economic crisis.

Above all, however, Krugman and everybody else want job growth combined with economic growth. The problem is that the current massive amount of government spending is poorly designed to deliver this.   John Maynard Keynes famously called for the government to “prime the pump” with government spending for goods and services to stimulate the economy but the 2011 Federal budget included over $2 Trillion in mandatory spending and most of it was spent -quite literally – on people who are NOT WORKING. Social security for retirees and people with disabilities. Medicare for people older than the traditional retirement age of 65. Medicaid much of which is for children and those on disability. Unemployment benefits for . . . . people who are unemployed! And the recent bank bailouts designed to keep bank employees who already have jobs from becoming unemployed.  Even recent massive spending on two wars was primarily spent overseas during the occupations to employ Iraqis, Afghanis, and other foreigners. In theory and except for Federal employees, US government spending does not result in the creation of a single new American job.  It helps to maintain the status quo. No wonder the recovery has been jobless and sluggish.

During World War II the US government spent several hundred billion dollars to directly employ Americans to provide goods and services for the war effort. The economy responded with the biggest peacetime expansion in history. But today we have a multi-Trillion dollar economy and a few hundred billion dollars in domestic spending here and there is not going to cut it. What is needed is a multi-Trillion dollar domestic spending bill for the direct employment of Americans for nationwide infrastructure improvements. Unfortunately, we’ve already used up our political capital with year after year of massive deficit spending regardless of crisis. At least World War II had an end. By 1946 we no longer needed thousands of tanks, planes, and ships to fight the fascist threat and so spending decreased dramatically to prewar levels. This fiscal rationality no longer applies. For three decades, nearly every Federal budget has been followed by an even bigger budget. We no longer have either the political foresight or will to constrain spending so that we can reserve massive spending increases for times of true emergencies.  We have been spending our “rainy day money” on sunny days and now we have nothing left.

Answer:      It depends on how much the client pays them.

Doctors don’t usually have the luxury of choosing when they will need to be contacted for some “emergency” or whatnot. Throughout history, physicians have needed to depend on a messenger service of some type to remain in contact with their patients. Before 1950, physicians were paged over a hospital’s public address system or called at their home or office but then Charles F. Neergard,  a radio engineer annoyed by the constant overhead pages for doctors, developed the first wireless paging system. After this, pagers gradually evolved from radio voice paging to alphanumeric pagers and then digital. Answering services were added to streamline the service and add multiple physicians to the same service with a single number.

Then came cell phones. Now, it’s not that personal wireless phones are a bad thing. The biggest problem with having a pager and an answering service was having to hunt around for a land line phone while in a restaurant, or at the ball game, or the movies, or while watching naked midget wrestling, or whatever. With a cell phone, a return call was as near as your belt or purse.

But then the hospital staff or the ER physicians or whichever moron is in charge of these kind of things decided that since pretty much every physician these days has a cell phone on their person, it would be the best idea since ritual sacrifice to bypass the whole answering service-pager route and make the calls directly to the physician’s cell phone. Aquiring a physician’s personal cell number is as easy as taking the number from the caller ID and disseminating said number to any and all interested parties. So instead of having to deal with the “hassle” and time of calling an answering service and leaving a message to have Dr. So-and-so call them back, all they have to do is to place the call directly. It’s easier than ordering pizza!

It took all of a few days for the staff at the hospital where I started working a year ago to begin bypassing my answering service and call me directly. At first I just dismissed it as an occasional annoyance but then it became so common that my answering service was rarely used. It continued in mass even after I tried to politely ask the staff to use the answering service on every call. I found my cell phone number on slips of paper and on cards tacked up at most of the nurse’s stations.  After  several meetings with the hospital administration and department heads the calls became much less frequent  and yet they continued intermittently.

So what’s the bid deal? What could possibly go wrong? A direct call to a physician minimizes a delay that may occur when an overloaded answering service has a backlog of pages to send through and it eliminates the need to wait for the doctor to call back. Certainly in an emergency situation time is critical and this has to be the best way. Except it’s worst way.

First off, during business hours when I am seeing patients in the hospital or office, I treat my personal cell phone as my primary business phone. This means that I do not answer it when I am having a delicate and complex conversation with a patient or family. I am not going to stop to answer my phone in the middle of a conversation with a patient about their diagnosis of cancer (I have it on vibrate only). Nor do I allow phone calls to interrupt conversations with other physicians or consultants or the nursing staff.  And I hate to get interrupted with a cell phone call while I’m in the middle of a dictation over the hospital phone system.

So I started ignoring phone calls during these times and an interesting thing happened. I found that having initially allowed these calls gave the hospital staff a new sense of entitlement; an expectation that they would be able to reach me instantaneously and easily with one phone call. And when I didn’t answer I started to get complaints such as “Dr. Rangel doesn’t answer his phone when we call him and he is hard to get ahold of.” Amazingly enough, I was very easy to get ahold of when the staff utilized my answering service. Even more amazing was their reactions when asked if they had tried the answering service in the first place. They often seemed confused as to which method was supposed to be utilized first and which was intended only as an emergency backup. Or they didn’t particularly care.

The primary motivation for the hospital staff to call me directly appears to be laziness rather than any concern about efficient communication. With a single call direct to my phone, a staff member or ER physician need not hang around waiting for the answering service page to go through and for me to return the call. But my job description does not include being at the “beck and call” of the hospital staff nor to make their jobs easier.  Only after I stopped answering direct calls from the hospital did I realize how many were frivolous or inappropriate rather then for urgent patient care needs. I noticed that the nursing staff began to seek me out or to make themselves more available to talk with me during rounds about any questions they had regarding patient care rather then knowing that they could just call me later.  I had fewer confused calls from the ER docs about admitting patients who were already established with other physicians. It had been easier for the ER docs to call me directly than to contact the patient’s primary care physician.

What about emergent communications? Isn’t a direct call faster and safer? Actually, a direct call, in an age of texting and alphanumeric paging can be detrimental in the event of an emergency since the caller ID provides only the calling number and not the reason for the call. In other words,  I can’t tell which phone call is emergent and which is from a nurse asking for an order for  a stool softener. On the other hand, my answering service can text me the number to call back and whether or not it’s an emergency. This allows me to prioritize tasks so I know if I need to interrupt a patient’s detailed description about their bowel movements to return a call. Besides, there are multiple resources that the hospital staff can utilize (ICU rapid response team, nursing supervisor, in-house ER medical staff) for an emergency in addition to contacting me. They shouldn’t be paralyzed with inaction while waiting for me to answer my phone.

And there are many other excellent advantages to utilizing my answering service. The service knows when I am off or out of town and to direct calls to the covering physician.  The service will call the hospital unit back to confirm with the nursing staff whether or not I have returned the call and if not they will page me again.  The service keeps a log of every call which will help me defend myself against hospital staff who claim to have called me for an urgent situation when, in fact, they didn’t.  As mentioned above, the service can provide other additional information in a text that can’t be provided in a direct phone call.  And lastly, I’m paying for the dam answering service so the hospital better well use it!

Admittedly, there are many physicians why actually prefer to be called directly for reasons that I don’t understand (maybe they’re too cheap to pay for an answering service). I’m not one of them.  Just because technology has advanced doesn’t mean that we should automatically use it and abandon older proven systems.

New data show that total spending by insurers, government agencies and individuals amounted to $6,238 per resident in 2009, well below the national average of $6,815. That puts California on a bottom tier with Arkansas, Georgia, Texas, Utah, Nevada, Arizona, Colorado and Idaho.

God forbid that California be in the same category of anything with those red states! It must be like west coasters finding out that Newt Gingrich is a diehard 49ers fan. Then came the blanket statements that blames lower health care spending for a sicker population, less productive work force, and the general downfall of civilzation.

“The state is essentially under-investing in healthcare and ending up with an unhealthier population as a result,” he said. “If people aren’t healthy, they are not able to work or to be as productive as they otherwise would be.”

But it’s not at all certain how spending on health care directly or indirectly affects worker productivity and economic growth. The problem is one of being able to separate the variables from each other. For example, health care spending is well known to directly correlate with older and wealthier populations.  States with a higher percentage of older citizens such as those in the North East and Florida spend more on health care than states with a younger median population like California and wealthy countries spend more on health care than poorer countries.

The overall health of a population (as measured in higher life expectancy, lower infant mortality, lower rates of disability, etc.)  certainly does correlate with better productivity.  But economically advanced and productive populations tend to be healthier which promotes increases in productivity which increases wealth and so on. Ergo, this self defining metric is not very useful and it not at all the same as the level of health care spending.

Another problem with trying to study population health and health care spending is determining cause and effect. Obesity is a good example. There is very good evidence that obesity and obesity related health problems directly leads to $40 Billion per year in excess costs to the Federal government. But there is no good evidence of the reverse.

Indeed, health care spending in this country is almost all reactionary and not preventative. States with older populations spend more. States with higher rates of unhealthy lifestyles such as obesity, smoking, and substance abuse spend more to deal with these miladies. The primary philosophy of US policy makers regarding health care spending appears to be little more than, “the squeaky wheel gets the grease.” And right now California has the benefit of being one of the healthiest states with low rates of obesity and smoking as well as being one of the states with the youngest populations.

In the same way that lower spending on fire fighting equipment and supplies is due to the fact that there were fewer  rather than more fires, the total level of health care spending should not be confused with worsening public health. Better metric analysis should focus on the numbers of and access to primary care providers, basic and affordable medications, neonatal and women’s medical care, and efforts to reduce pain and suffering in the elderly and terminal patients. Right now the US spends far too much on expensive and often frivolous medical care.  A smarter question should be, “are we spending enough on the right things” and not just “are we spending enough?”