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.

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.

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?”

Enter the late Senator Ted Kennedy who advocated for a government run long term care insurance program and thus CLASS (Community Living Assistance Services and Supports program) was born as part of the mega health care reform of 2009. Except it was stillborn.

Basically, liberals looked at the long term care of rich retirees or at least those who had the foresight to purchase a long term care policy and decided that this is a new entitlement that everyone should be able to get regardless of financial ability! So they decided that they could perform a magic trick and create a government sponsored and run long term care insurance program with monthly premiums as low as $5, a short 5 year purchase period before becoming eligible for benefits, no apparent age or time limits for benefits, and no underwriting in the selection of beneficiaries. Basically it was an insurance plan without any of the rational limits and restrictions that real insurance companies use to prevent themselves from going bankrupt.

CLASS didn’t even provide all that great a benefit compared to most private policies which usually provide $200-400 per day coverage. But even a $50 a day in-home care assistant to help with cooking, cleaning, and bathing would cost over $18,000 a year.  Nursing home care would cost even more. And with no signup restrictions and no increased premiums based on overall health and age at the time of signup, the possibility that the vast majority of beneficiaries in this program would be the sickest and most infirm was too much to be able to assure that the program would be solvent in 75 years. Thankfully, an amendment was added to the act that required the department of Health and Human Services to prove to Congress that they could perform magic and create a stable and self sustaining program.

They couldn’t. And perhaps for the first time in history, a disastrous social program that would have cost the tax payers an additional $75 Billion per year was stopped before it could join the phalanx of entrenched entitlements. Once again, liberals have proven that you can’t pull water from a stone, create gold from lead, have your cake and eat it too, or buy something without paying for it.

CLASS failed for the same reason that Medicare is failing. The amounts that people pay into the system are falling short of matching the actual costs. Like CLASS, Medicare has few restrictions on the amount and types of care that beneficiaries receive. Liberal egalitarianism (“health care is a right”) demands that a severely demented 99 year old nursing home patient with terminal cancer receive the same life extending care as a 65 year old with no medical problems.

In a way, CLASS was even worse. It tried to create a new social entitlement where it’s debatable if there even is one. Despite hysterical claims otherwise, long term care boils down to one single benefit. Comfort. There is no proof that nursing home care or home assistance care or assisted living or adult day care increase life expectancy or prevents such old age maladies as falls, hip fractures, pneumonia, or strokes.

Severe cost over-runs raise the issue of whether Medicare should continue to provide for such aggressive care in those over 80 and CLASS raised the question of whether long term care is even the way to approach caring for our elders. Only about 50% of the population needs a nursing home stay at any point in their lives and the average nursing home stay is usually less than a year. The majority of elderly patients who do need assistance are cared for at home by family members or in some community care setting. Home and community care is far less expensive than facility care or having daily private assistance. More attention should be paid to assisting those families who do make the time and effort to care for an elderly loved one at home.

Then there is the rational approach to caring for the elderly. Statistically, a patient who has deteriorated in their ability to care for themselves and live independently as a result of advanced age and/or progressive medical conditions has a far shorter expected survivability than one who is relatively healthy regardless of aggressive medical care. The CLASS act does not appear to concentrate or particularly promote the option of hospice care (even for patients without a specific terminal illness) nor is there a provision to promote comfort over continued aggressive medical care. I can guarantee you that the vast majority of patients in a long term care situation continue to receive aggressive health care including blood pressure medications, statin medications to lower cholesterol, mammograms, colonoscopies, frequent testing and office visits, and frequent trips to the ER for any cough or fever or issue other than one strictly of comfort. Aggressive medical care accounts for a big part of the cost of caring for the elderly.

The Medicare lunacy of continuing to treat elderly patients in the last few weeks, months, or year or two of their lives with aggressive medical care designed more to extend lifespans rather than to promote comfort is a big part of what sank the CLASS act. Rather than concentrate on keeping the elderly alive and warehoused in facilities or with expensive home services indefinitely for the benefit of the working poor, the CLASS act might be still viable with a change in philosophy. The same goes for Medicare.

At some point (probably just before complete economic collapse becomes inevitable) the deficit will need to be paid back and right now that amounts of almost $50,000 per every single American.  Of course, this only applies to tax payers and inevitably those with higher incomes will be “called upon” to shoulder more of the debt burden. But beneficiaries will also have to pay the price of decades of deficit spending as social programs and entitlement benefits are slashed to bring spending under control. Essentially, everyone will pay in one way or another.

Fortunately, deficit spending can probably continue for many more years before the bottom falls out and we all end up taking night classes in Chinese. This is just what the current bunch of drunken sailors on a Tijuana spending binge that passes for the US Congress is counting on.  Re-election is more likely as long as members can continue the spending insanity and delay the inevitable hang-over until well after they have left office.

The health care industry and physicians in particular are doing almost exactly the same thing.

The current reimbursement system (as directed by Medicare) rewards volume over quality and invasive procedures over good medical management. Therefore and in the face of shrinking reimbursements, physicians have continued a pattern of high volume and high utilization of health care resources.

Currently there are absolutely no good incentives and fewer reasons for physicians to practice good resource utilization and try to contain health care costs.  A few managed health plans will “reward” their participating primary care providers by “sharing” a little of the savings from their efforts to reduce costs. But these kick-backs are usually a very small percentage of the over-all savings.  What about passing savings on to their patients? In my experience, patients infrequently ask their providers to help them out with less costly tests and treatments and any concerns are usually limited to medications. This is what happens in an insurance system. Costs are separated from the source. This disconnect impairs how both providers and patients understand and react to costs.

But not truly understanding and being separated from the economic consequences of their practice is only the background of how physicians are contributing to the escalating cost crisis.  There are so many other factors that “reward” physicians to totally ignore resource utilization and order more expensive tests and treatments for their patients. There’s ignorance among doctors that more expensive tests and treatments are better. There is fear of litigation and other reprisals and having to explain why they didn’t get the test instead of why they did. And then there is outright greed either to see a ton of patients a day (on the part of primary care docs) or to perform a ton of procedures (among specialists). There is even institutionalized greed among health care facilities to admit and treat the most patients and to perform the most expensive procedures which simply enables those aggressive, high cost physicians.

If you’re not part of the solution then you are certainly part of the problem. Unless physicians take responsibility and assume (or rather, re-assume) some leadership in our health care system the consequences of ever increasing health care costs will be ever drastic and larger funding cuts.  If physicians don’t stop responding to decreasing reimbursement rates by exploiting new revenue sources or simply increasing volume then the system will bring back managed care . . with a vengeance.

Our wild spending spree will have consequences. The problem is that no one knows when the tipping point will come. I’ve tried to talk to other physicians about this. The blank stare or shrugged shoulders they give me is similar to the responses I get when I talk to 20 somethings about the dangers of smoking.  The threat is currently too abstract. Like Congressmen, the hope is that they will be long retired and out of the profession before the proverbial excrement hits the fan. At that point, it will be someone else’s problem.

I’m not advocating for socialized medicine or some universal health care government scheme. I’m certainly not an anti-capitalist. The problem is that the current health care system is not so much capitalist as it is a gigantic privatized government program. As such, there are few  classic capitalist mechanisms as cost transparency and free markets in this system, which is great for recipients of the funding. It’s great, until the bottom falls out.

In concert with such actual and true reforms such as malpractice tort reforms and reimbursement reforms and stabilization, physicians need to convert from simple “consumers” of the health care system and start acting more like advocates, reformers, and preservationists of the good things about our system (freedom of choice, efficiency, advanced care) before the US gets it’s own National Health Service nightmare.

You know the score, pal! If you’re not a cop, you’re “little people.

Little People. Yea. In the realm of hospital politics, if you’re not a highly paid specialist . . then . . you’re little people.

Recently I was privileged to have had a conversation with the head of the emergency department of the big-national-conglomerate-owned hospital where I work.  One of the admissions to the medicine service overnight had turned out to be a patient with a fracture. The surgical specialist on call had requested that the ER admit the patient to the medicine service even though the patient was young and didn’t have any medical problems. The patient also had no insurance.

[Me on the phone to the ER director]: This was not an appropriate admission to the medicine service. There are no medical issues. Not even anemia. The patient’s blood pressure is better than mine right now! The only time the medicine service ever gets requested by the surgical specialists to admit a patient is when it’s an un-referred patient through the ER who doesn’t have any insurance regardless of whether they actually have any medical issues. They never ask us to admit their insured private patients! And unlike the surgical specialists, we don’t get paid to cover un-referred admissions from the ER!

[ER Director]: The surgical specialists don’t do their own admissions. They just consult.

That’s it. That’s the stark logic of reality that the ER director provided. But for those of you who missed it, I’ll provide a translation.

[TRANSLATION]: Federal law requires that we (the hospital) provide the same surgical services in the ER as we do in the OR regardless of the ability of the patient to pay. Therefore, we require the surgical specialists to be on call for the ER to provide this service. We pay them a fixed stipend (usually as much as $700 or more for each call day) because they also bring their private insured patients to this hospital for procedures that can make up to $25,000 to 30,000 for the hospital. We want to keep their business so we pay them to cover the ER. We pretty much give in to any of their demands like allowing them to consult only and not be the admitting physician on ER cases since this comes with more responsibility and paperwork than a consultant.  In contrast, you medicine people make the hospital far less money. We’re lucky to usually brake even on your patients. In short . . you’re not surgical specialists. You’re little people.

Often these types of admits are far simpler and quicker to do than the average Medicare, complicated, medicine patient so is it really that big of a deal? Yes, it is.

Bedsides the principle of being discriminated against without so much as pat on the ass, there are the issues of uncompensated time and effort being taken away from insured patients and needlessly and involuntarily taking on the increased liability. In the current system, the hospitals often get some type of reimbursement from Federal and state grants and programs to help pay for care of the uninsured while the doctor is usually the last one in line to receive any compensation. We can’t write this off as a business loss since the patient was not seen in the office. Nor can be write this off as a personal tax loss.  And far too many of the uninsured consider health care to be a “right”. I.e. something they are entitled to without having to pay for it.

The take home point here is that this is just another reason to avoid going into primary care if you or a loved one are thinking of becoming a doctor. Avoid it like the plague.  Money (or sex) begets power and primary care physicians are at the bottom of the reimbursement totem pole.  Not only do we not get paid well, we don’t even have the power to avoid becoming modern indentured servants.