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More on Ebola

1. Today, driving to work, I heard NPR’s report of how Facebook founder Mark Zuckerberg, and his wife, had a revelation that third world countries have poor sanitation facilities and this fact relates to the out of control Ebola epidemic in West Africa. This apparently occurred while Zuckerberg was traveling in India, and moved him to pledge $25 million for immediate use for public health work in West Africa. Right after that, NPR reported that world stock markets were falling as the business community realized that the Ebola crisis might affect their bottom lines. This is all good news. As I predicted earlier this week, as soon as the captains of industry who give our political “leaders” their marching orders, get concerned about losing money, there will be an intense effort to stem the spread of Ebola. Zuckerberg is young. He has been too busy making money and meeting with political leaders to know what the Third World looks like. Zuckerberg’s lack of knowledge about sanitation in the Third World is not surprising. I hope he was told not to shake anyone’s left hand there. For those of you who don’t know, the left hand is used instead of toilet paper.
2. Some comments about defensive medicine. It strikes me that what all the experts and population are calling for now is defensive medicine to stop and monitor Ebola. Things like checking lymphocyte counts daily in people exposed to Ebola victims and close monitoring of temperatures. “Defensive medicine” has been the pejorative term used by the business community and their lackeys in the press and legislatures to rail against lawyers who represent victims in malpractice actions against doctors and hospitals who don’t follow “protocols.” As in they didn’t follow the protocol or train nurses in the use of the proper protocol to treat Ebola and now the entire city is exposed. What the critics of current Ebola practices at Texas Health Presbyterian Hospital are calling for is “defensive medicine.” This brings to mind an observation taught to me by the late Harry Schwartz – economist and New York Times editorial page writer – that peoples’ concerns for health care costs are inversely proportional to how sick they are. And Mittler’s corollary: and how scared they are of the Ebola epidemic. When all you worry about is the common cold or indigestion, you think that all the public health measures and expensive specialists are frivolous (like all lawsuits) and a waste of your hard earned tax dollars, that could be better spent on Dallas Cowboy jerseys or dog sweaters. But when the Ebola virus threatens, people want daily blood tests, specialized treatment centers, a fleet of jets to transport victims, and hot and cold running infection disease specialists to save their lives.
3. Less is more: The mantra of so many medical journal editors, like Rita Redberg of JAMA Internal Medicine is that “less is more.” Greedy doctors doing too many unnecessary testing and the need for managed care executives to rein them in. How many medical journal editors are calling for HMO executives to take over the management of the Ebola crisis? The public wants the biggest experts and the best facilities money can buy? Take a poll: How many of you would trust Kaiser or Humana to run the national Ebola response team? Would that number approach zero or be zero? How many in the public trust Texas Health Presbyterian Hospital to run their Accountable Care Organization?
4. My impeccable source tells me that yesterday an elective heart valve replacement surgery was cancelled at Texas Health Presbyterian Hospital in Dallas due to reasons not explained to the patient.
5. This past Monday, 10 orthopedic surgeries were cancelled at one northside San Antonio hospital due to several operative room personnel not showing up. The doctor who told me about that could get no explanation as to why this happened. He was upset because one of his patients was already in the operating room holding area being prepped for surgery when the cancellations were announced. Do you think that hospital will “self-report” to the Texas regulatory agency that monitors hospital quality? You can be sure that if any surgeon cancelled at the last minute and that surgeon wasn’t a big hospital admitter, he or she would be hauled before a peer review committee. BTW, that won’t happen in this instance because most of the surgeries involved one surgeon who is a big Accountable Care Organization medical politician at that institution. So, patient inconvenience is the only fallout, and who cares about that?

Zeke Emanuel Now Ebola Expert Too?

Zeke Emanuel Now Ebola Expert Too?

It’s hard to know where to begin this AM.

1.      At 5:04 CDT, “Morning Joe” brought on Zeke Emanuel as their Ebola expert. Give us a break! It’s hard to know who America’s Doctor is these days. Back in the late 1980s, it was easy: Surgeon General C. Everett Koop. But now, we have Zeke Emanuel, vying with Sanjay Gupta who is vying with Sandeep Jauhar who is vying with Nancy Snyderman and don’t forget Atul Gawande.  I’m waiting for some network to bring on 100 year old Professor Irwin Corey – “the world’s foremost authority” to straighten out the Ebola mess. Gupta “debated” Dallas Congressman Pete Sessions on CNN’s “New Day” on the issue of quarantining West Africans to prevent the spread of Ebola and did not fare well. Sessions accused him of everything but child molestation for suggesting that it was hard to enact an effective quarantine.

2.      Speaking of NBC’s Snyderman, over on CNN this AM, there was some hilarious subtle old-school doctor-bashing. There was a story on how the NBC reporting team had been put in voluntary quarantine in the U.S. after their cameraman came down with Ebola. And apparently Dr. Nancy Snyderman did not observe the quarantine.  http://planetprinceton.com/2014/10/13/princeton-police-and-health-department-enforcing-quarantine-of-nbc-crew/

Anchor Michaela Pereira slammed Snyderman saying she was seen driving around in a Mercedes! Ouch! That’s really a dig, accusing a doctor of driving a fancy car. (It was a black Mercedes according to Planet Princeton.) Appealing to the politics of greed and envy always works. Maybe Pereira should have checked to see how much Mercedes – the car company — spends on ads with CNN, before knocking an advertiser. I thought rich doctors and even richer doctors who are network TV medical editors are supposed to drive fancy cars.  But we have all been trained by the national media that when doctors drive fancy cars, it is because they have made too much money from doing self-dealing unnecessary tests and procedures. Especially those done in the middle of the night on hapless acute heart attack victims.  Or taken too many billions from the former cheerleader drug reps.

3.      Maybe somebody out in the blogosphere can explain why we need so many news teams in West Africa covering the Ebola epidemic. Don’t we already know the basic story: thousands are dying from the disease in countries where there are few doctors, poor sanitation, poor health facilities, weak public health systems, and leaders who for many years have looted the countries and oppressed the people? Can’t we get the story of the deaths from pooled news coverage?

4.      Then we have the story today by Robert Pear in the New York Times that audits of Medicare HMOs show they are denying necessary medical care. http://www.nytimes.com/2014/10/13/us/us-finds-many-failures-in-medicare-health-plans-.html?_r=0

Is this really news? That’s what Medicare HMOs are paid to do: deny care and do the rationing dirty work that federal officials are too afraid to do.  Pear has been covering Medicare HMOs for over 20 years. He wrote a big story in the 1990s about how Medicare HMOs weren’t saving money.  This isn’t his first rodeo – on this subject. But Pear and his editors only quote from the government audits and responses from HMO executives. He never uses one source who has been a long time critic of Medicare HMOs. He never cites one of the medical literature articles that showed that Medicare HMOs promote underuse.  He knows who the critics are but didn’t choose to put any such view is in his article. I’ll just file this under another example of incomplete reporting by the America’s newspaper of record. But hey, they own the newsprint.

5.      Speaking of Medicare HMOs, I saw a Humana Medicare HMO TV ad on 10/12/14 at 0529 playing on ESPN.  The ad started “Zero, Zip, Zilch,” and proceeded to show all the services enrollees would get for “free.” This is the essence of HMO advertising: everything is “free.” These are deceptive ads and I have complained about such ads in the past – with no success.  Medicare Advantage is not free. It is subsidized by U.S. taxpayers.  No out of pocket expenses does come at costs: lack of freedom to choose your doctor, narrow networks, restrictions on consultants, and extra payments if you want to go outside the defined networks, and a restricted drug formulary.  You could say that gullible seniors both deserve and don’t deserve what they get. Caveat emptor.  By now, everyone should know that there are no free lunches in health care. But, there are many elderly folks who are not sophisticated or who have various impairments and who need the government to protect them from such deceptive advertising, not throw them to the HMO marketing wolves. And don’t expect National or Local media to protect seniors. They’re all hooked on Medicare HMO advertising dollars.

6.      The most significant stories today deal with the failure of hospitals to properly prepare the staff members to deal with Ebola. It’s not just nurses who have been poorly trained – if they received any training at all, it’s the lab and x-ray techs, respiratory therapists, and other critical hospital personnel. Meanwhile the highly paid administrators are probably more concerned about when and if the stock market will correct.

7.       The U.S. will get serious about Ebola when corporate chieftains tell their politicians on retainer to solve the problem. Until it affects McDonald’s or GM’s or Apple’s or Starbuck’s bottom line, our political leaders will continue to dit

Global Competitiveness

“We all have a stake in improving the quality of care we receive while spending our dollars more wisely,”

“It’s good for businesses, for our middle class, and for our country’s global competitiveness.”

HHS Secretary Sylvia Burwell

For anyone who believes that I have been out of line in linking the national obsession by health care pundits, economists, and managed care apologists to destroy fee for service medicine in the name of enhancing America’s global competitiveness, you just have to read a recent observation linking the two by our current HHS Secretary.

The link was buried in a story reported by The Hill and others about savings from the nation’s Accountable Care Organizations (ACOs). http://thehill.com/policy/healthcare/217881-small-savings-reported-from-new-healthcare-models

Only about half of the ACOs that reported their financials had savings. See Jordan Rau’s excellent report on this complicated topic for Kaiser Heath

News:http://capsules.kaiserhealthnews.org/index.php/2014/09/one-quarter-of-acos-save-enough-money-to-earn-bonuses/

I am mystified about how ACOs enhance our “global competitiveness.” But that’s what happens when you just have medical and law degrees but not an MBA or a PhD in economics from a prestigious Ivy League University.

Does it mean we will use the savings to build more prisons? We already lead the world in the number of our citizens – now disenfranchised from voting – we have in prison. And the private prison owners/political donors are laughing all the way to the bank.  Or maybe we can pay for more re-cycling of closed prisons as immigration – er future voter – living quarters?  Isn’t it ironic that we put our citizens in prison and they lose the right to vote, but when immigrants are put in the re-cycled prisons, they are way stations on the path to vote?    Again, I don’t have a degree in criminal justice or political science so I can’t understand the process.

Will we have more money for higher salaries for professional athletes under indictment for domestic violence and child abuse? We already lead the world in that.  Young doctors should be proud that our average professional baseball player makes well over $1 million per year, and an unnecessary test ordering pediatrician gets an exorbitant $120k or so.

Will it increase the amount of money we have to spend on pets – who are considered members of the family? I think we lead the world on that, too.

Will it increase the amount of money we have to spend on golf? We have been pretty bad at Ryder Cup play in recent years and sure need a boost there?

Maybe it will help us wage better wars (err counter terrorism efforts) in foreign lands? We lead he world in that too, but never have enough money to spend on foreign adventures to prop up defense contractors and other big political donors. See owners of private prisons above.

Or maybe we can give some subsidies to GE so it can sell more CT scanner in China.  I hear doctors there like to use them to order unnecessary tests to enhance income – at least according to the Wall Street Journal.      

Maybe we can build more Chrysler and GM and Ford cars? After all, they deserve the same tax incentives that Tesla got in Nevada. And the “Big Three” auto makers are always interested in telling doctors how to compete even though they can’t figure out how to build cars that can compete with their South Korean, Japanese, and German rivals.

And I’ll pose the eternal Uwe Reinhardt question that never gets answered: “Why is it good when Americans buy cars, but bad when they buy health care?”

What’s very clear is that in the not –too- distant future ordering unnecessary care for some dying senior with heart failure will be viewed as a felony punishable by prison time because the doctor who ordered it placed that individual’s selfish will to live over promoting America’s global competitiveness –whatever that is.   He wasn’t a good team player and the taxpayers need to finance his prison stay to help preserve our country’s global competitiveness.

Here’s my last question: What happens when we get rid of fee-for-service medical payments and everyone is in managed care with fixed contribution payments?  How do we enhance our global competitiveness? Maybe start HMOs and walk in clinics on Mars?

VA cover up of deaths at Phoenix VA hospital

Watch today’s hearing of the House Committee on Veterans’ Affairs about whether the VA’s Inspector General (IG) was trying to cover up the VA’s responsibility for the many deaths it evaluated and reported on in its August 26, 2014 report.

http://www.va.gov/oig/pubs/VAOIG-14-02603-267.pdf

I totally agree with VA whistleblower, Dr. Sam Foote, who is testifying today that the report was a cover up.

Even a casual reading of that report raises considerable suspicions. There is negligence galore, but being lawyerly, the IG stopped short of finding causation.

Here’s the sentence on page ii of the report that all the national media reported:

“While the case reviews in this report document poor quality of care, we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans.”  (my emphasis added)

Don’t believe that.

Go to page 17 and look at Case 30. First there is new pain diagnosed and treated over the phone. We aren’t told which pain medication was dispensed. Was it a narcotic painkiller?  For sure that was below the standard of care.

Then there is a two day delay before the patient goes to the Emergency Department complaining of 10/10 severe abdominal pain. This is spite of the new painkiller. The patient was hypothermic and had a fast pulse rate of 111 beats per minute. First diagnosis is sepsis and maybe septic shock. We aren’t told a blood pressure. Then there was a 2 hour delay getting a CT scan of the abdomen which showed a perforated bowel. Then a 4 hour delay getting a surgical consult. Then the patient was seen by a resident (doctor in training) not a senior staff physician. Then another 2 hour delay before being taken to surgery. Then we are told that the patient had to be maintained on blood pressure support and a ventilator until he died 2 days later.

And the VA’s IG wants us to believe that none of the poor quality care documented in this case report was a causal factor in this veteran’s death?

They sold it to the national media on August 26, 2014. The AP, NPR, the TV networks. All took the bait.

Where was ABC-TV’s Dr. Richard Besser – he of CDC and unfair hair fame? Did he bother to read the report? Did he get to Case 30?

I hope the doctor-Congresspersons on the House Committee grill the VA IG today about all the cases, but specifically about case 30.

Someone needs to ask the IG when the patient in Case 30 got antibiotics. For every hour of delay in getting antibiotics in a patient with sepsis there is a significant increase in the death rate.  Someone needs to ask the IG is sepsis was diagnosed prior to surgery.

And someone needs to demand that the VA release details of all the case reviews to the families. The report says the VA is thinking about doing this.

I am sure that their lawyers have determined what they think are applicable statutes of limitation and repose for all the cases and don’t want to give any family any details of negligence until a time when they think they are safe from a lawsuit.

Watch today’s hearing to see if the VA gets away with its cover up.

Book Review of “Doctored” by Sandeep Jauhar

The New York Times has outdone itself in doctor-bashing by publishing two reviews of the same book: Doctored. The Disillusionment of an American Physician by New York based cardiologist Sandeep Jauhar.  Both reviews are by journalists who obviously dislike doctors – probably until they need one.  Susannah Meadows wrote one review for the Book Review section of the Times. And Florence Williams – she, the author of Breasts described as having “double D talents as a reporter” – topped all the other reviewers in her attack on hapless physicians. The Times editors thought Doctored so important they published the second review — by Williams– in the Science Times section on September 09, 2014.

Dr. Sandeep Jauhar is who is a Long Island cardiologist who expert in heart failure, and a regular writing contributor to the Times. Ditto for reviewers Williams and Meadows.

Let me state at the outset that Jauhar is a stooge. One definition of a stooge is: “a person who serves merely to support or assist others, particularly in doing unpleasant work.”  Jauhar is a smart guy who has been used by the editors of the Times and the Wall Street Journal to further their political agenda of destroying fee-for-service medicine and private practice and deliver doctors into the hands of millionaire managed care executives and overpaid millionaire hospital administrators so that Americans can get high quality care, instant access to the best primary care doctors – but not specialists , and lower costs so as to preserve America’s global competitiveness – whatever that is.

Here is some of Williams’ “double D” doctor-bashing rhetoric:

“.. he finds himself underworked, underpaid, and pressured to cut corners in every direction.”

“to relieve money and stress, he does something he dreaded…He moonlights on weekends and  evenings for a private cardiology practice…”

“…an astute critic of the wasteful, mercenary, cronyistic and often corrupt practice of medicine today.”

“The fee-for-service model leads to overtesting, dis-organization and redundancy.”

“..wanton consultation..”

”Many of the doctors themselves are greedy, defensive, and untrustworthy – including, at times, himself.”

I just finished reading the book, complete with annotated sticky notes and underlining.  The first I saw of the book was in a long two page excerpt published in the Wall Street Journal’s Review section on August 30-31, 2014. The WSJ also published a review by a Harvard professor that was a lot more tempered than the reviews by Meadows and Williams.

Both the conservative WSJ and the liberal NY Times have long agreed in their news sections that doctors are greedy and incompetent and have to be reined in by managed care. They obviously love a guy like Dr. Jauhar who is a doctor-bashing doctor.  It takes Dr. Jauhar exactly 9 pages in the introduction to his book to conclude that doctors are responsible for their own woes because they were corrupted by Medicare into performing millions of unnecessary surgeries and were “bilking” and “mismanaging” their patients. Jauhar trumpets HMOs as the cure for doctors’ greed and claims the HMO was invented in the 1970s when in fact they first appeared on the West Coast in the 1940s. And Jauhar could have easily found the House Subcommittee on Oversight and Investigations report on “unnecessary surgery” from 1975 which he cites and read the testimony of the chief of surgery at Johns Hopkins who pointed out that “unnecessary” surgery was hard to define and for doctors to agree on.

But Jauhar only needed some evidence and I’m certain his editors at his book publisher and the editors at the Times and the WSJ could care less whether the evidence for unnecessary   surgery or “inappropriate” care was valid or not as long as it had been the conventional wisdom of those eager to take over medical decisions from doctors  – like the various business groups on health, to name a few.

What is ironic and more than a little inconsistent, is that Jauhar goes from bemoaning too many surgeries on page 10 of his introduction to on page 11 bemoaning the fact that doctors are not doing enough preventive and screening procedures because of the time constraints of managed care. Either way, I guess doctors are at fault and the doctor-bashing editors were pleased.

Jauhar’s book is a great read, don’t get me wrong. I loved the sections describing a corrupt subculture of South Asian physicians who (or through their assistants) order unnecessary echocardiograms and nuclear stress tests. That struck a chord of recognition of the same kinds behaviors in the same kinds of knaves – of all ethnic and WASP persuasions –right here in San Antonio. But Jauhar gives a false impression that all doctors in private practice are like that – corrupt and looking to do unnecessary testing or engage in fraudulent activities to bilk patients and insurance companies – as opposed to “academics” like him.  And the fact that he occasionally writes a disclaimer that not all doctors are corrupt makes me wonder how much his initial drafts were influenced by the three book editors he thanks for helping him.  Let’s face it: if he were not a critic of private practice doctors and fee-for-service medicine he never would get even one column inch in the NY Times.

I was charmed by his lyrical and amusing writing about the way many unnecessary echocardiograms were being ordered, until I was jolted back to the reality of my own experience of needing a third opinion at the Mayo Clinic in Rochester to get a transesophageal echocardiogram not ordered by my two prior nationally recognized consultants to diagnose a ruptured support structure of my mitral valve needing urgent surgical repair. And how the emergency repair itself was not supported by a randomized trial and the kind of evidence that insurance companies are demanding so they can bring the “knaves” in private practice – who Dr. Jauhar so well describes – under control.  Had my surgery been denied by my insurance company, I would today probably be a candidate for Dr. Jauhar’s services in his chronic heart failure clinic, if I were even alive today.

Reviewer Williams admits that “insurance companies have taken away doctors’ autonomy.”  And she does get one thing right: doctors can’t be trusted anymore. But for the wrong reasons. Neither she nor Jauhar understand that it’s not doctors’ inherent dishonest selves that patients can’t trust. It’s what insurance companies and hospital administrators make them do when the young doctors enter practice beset with debt and trying to balance family life and the often-oppressive demands of sick patients and anxious family members.   That’s what Jauhar’s book is about, but somehow he blames doctors for the mess they and he are in. He thinks they brought it on themselves.  And he has done a lot to undermine patients’ trust in their overworked and underpaid physicians – except for those few like him.

While he admits certain flaws and at least one case with a bad outcome, it is clear that he thinks he is better than most doctors and the media have anointed him as such to use his credentials and moderate sounding voice to levy all sorts of criticism on doctors trying to do a good job.

I see the same problems that Jauhar sees, but not that much knavery. And I have long written about how HMOs and managed care executives in concert with bought off politicians have destroyed the doctor-patient relationship. I chose to say no to HMOs from the very beginning when I was offered the medical directorship of the first HMO in San Antonio. But I was still was able to care for sick people, but not get rich. Jauhar wants to get rich to satisfy an expensive Long Island lifestyle. He should learn to say no and get his colleagues to say no to managed care.   I am not better than Jauhar, just different. He will be proven to be right because the Times and the Wall Street Journal have anointed him right. That’s what their corporate advertisers want and they will deliver the written history to fit their advertisers’ needs.

It is true that most young doctors are too weak and scared to stand up to managed care medical directors and hospital administrators who own their contracts. And who can really blame them? They don’t know any better. They haven’t been taught to be courageous. Their Machiavillain medical school professors never taught them that saving lives should take precedence over saving dollars. Please tell me the number of medical school professors and medical journal editors who have spoken out against the depredatory practices of managed care.  The answer: very few.

I think back over my numerous attempts to speak about the realities of managed care in San Antonio at our local medical school – the University of Texas Health Science Center at San Antonio.  Dr. Steve Cohen and I got to give one after hours lecture at night to students who wanted to attend. That talk was not part of any formal course. It was poorly attended. And I was allowed to give one noon brown bag lunch talk on the topic which was pretty well attended but still not part of any formal endorsement by the medical powers. It was sponsored by a drug company with ZERO editorial content control. Most of the students came to get the free lunch the company handed out. And I was not paid an honorarium. It was strictly a volunteer effort.

But, local medical students during the 1990s when national reporters regularly trooped to San Antonio to do then- popular stories on abusive practices of managed care entities –including a one year undercover investigation of the HMO industry — never heard any of their professors speak out about managed care. Medical politicians were and are too smart to poke big money in the eye. They are astute at playing politics to advance their careers. And the local media in San Antonio didn’t care to hear any of this either. They were too busy selling ads to the managed care companies and to car dealers who suppressed critical stories on managed care – according to one still working newspaper reporter here.

The editors of national papers like the WSJ and NY Times ( and the TV network producers who read their work to get their story ideas)  -as opposed to some few reporters in the news divisions –  use stooges like Dr. Jauhar to advance their political agendas – to break the back of fee-for-service medicine and deliver the medical profession into the hands of big corporations who call the shots in America and are big advertisers in their papers. These national papers just want to make money and if they can lower health care bills for themselves, their advertisers, and their poorly paid reporters and contributors like Ms. Meadows and Ms. Williams, so much the better.

You would think that if Dr. Jauhar were so upset by the control of managed care, one of the reviewers would see fit to talk about how managed care ( big insurance companies) have to be reined in. But no such idea is seen anywhere in the two Times’ reviews. Instead, there is bitter attack after bitter attack on doctors – and specifically doctors in private practice. The reviewers don’t criticize hospitals or hospital administrators that are buying up doctors’ practices and telling their doctor employees how to practice, as if they knew the right way to practice medicine – which they don’t – and in the process increasing the costs of medical care to medical consumers according to a recent court filing by 16 state attorney generals.

Are the reviewers are so naïve and ill-informed that they think that the “knaves” ( to use Dr. Jauhar’s metaphor borrowed from a top official of the American Board of Internal Medicine and buried in that doctor bashing medical journal, the Journal of the American Medical Association) in private practice – when they become hospital employed physicians – suddenly become “knights”?   Don’t the reviewers realize that the” knaves” in hospital administration seek out the biggest “knaves” in private practice to combine their talents to synergistically produce even bigger knavery?  If not, they should read the amicus brief filed by the state AGs in the Idaho case now before the Ninth Circuit Court of Appeals. See my previous blog on this subject.

Below are two unpublished letters to the editor I sent about reviews of Dr. Jauhar’s book. Both were written before I had read the entire book and were responses to the published reviews or book excerpt.

One letter was to the San Antonio Express News after they published an excerpt of Meadows’ review in the Sunday paper on August 31, 2014 Page F4.

RE: “Book examines dysfunctional medical system”

Susannah Meadows’ book review of Dr. Sandeep Jauhar’s memoir, “Doctored: The Disillusionment of an American Physician” correctly points out that Dr. Jauhar finds fee-for-service payment for medical services “poisonous” – as do many policy makers these days. First, it should be noted that Ms. Meadows is a veteran journalist who has covered politics not medicine or health policy. Second, neither she nor Dr. Jauhar answer the obvious question about changing to a payment system featuring salaried doctors with bundled and capitated payments going to their employers: If the greedy incompetent doctors can’t be trusted in a fee-for-service model where every charge and payment are explicitly listed, how can those same suspect practitioners be trusted to not under prescribe needed care and cut corners when their salaries and bonuses depend on not exceeding the fixed payment per patient? What suddenly makes these villains trustworthy? If you think that monitoring death rates in sick elderly patients will easily show up rationed care, think again. By the time the statistics become evident – if ever – it will be too late. Both Meadows and Jauhar conveniently ignore the medical mayhem chronicled by the media in the 1990s when patients were harmed by capitation –induced cost cutting. Many large medical groups that took on financial risk through capitation went bankrupt. There is no evidence presented that such risk shifting to doctors, hospitals and patients won’t result in the very same undesirable outcomes this time around. Jauhar’s book tells politicians and the media elite what they want to hear and fosters magical thinking about easy solutions to the high cost of health care.

This unpublished letter to the Wall Street Journal dealt with the excessive number of column inches they devoted to Dr. Jauhar’s book excerpt:

To the Editor:

Re: “Our Ailing Medical System” Page C1, August 30, 2014

“Here goes another letter that won’t be published. Just consider it occupational therapy but work for my forthcoming memoir that will tell it like it is and was – not the way Dr. Jauhar sees it.

The reason Dr. Jauhar gets so many column inches in both the “liberal” New York Times and the “conservative” Wall Street Journal is that he is a first string member of the doctor bashing team. I have reported for many years that doctor-bashing is a national media team sport. Both liberal and conservative papers bash doctors to satisfy their corporate advertisers who have decimated the profession of medicine over the last 40 years, while improving their bottom lines.

Jauhar gets media darling status – like your other favorite, Zeke Emanuel – because he recites the usual problems ailing American medicine: high health care costs, unnecessary testing, waste and fraud, “bilking the system” — and blames doctors for these problems. Therefore, his rising fame promoted by the national media. He then goes on to propose the usual solutions: end fee for service payments, go to bundled payments and capitation, and promote professionalism by medical school professors. Good luck.

Jauhar completely ignores the reality that doctors have become distressed because the profession has been subjected to a hostile takeover by insurance companies, overpaid hospital administrators, hospital community boards run by home builders, car dealers, and Junior Leaguers, and HMOs in the name of corporate greed. He should have said what doctors really need to do: strike. Let the Junior League do gooders and car dealers get their care from nurses at CVS walk in clinics while real doctors go to teach-ins to learn about how to practice in a truly professional way in which HMO medical directors don’t have the ultimate say on what is medically necessary. Don’t expect any medical school professors to be at such meetings. And don’t expect many doctors. Too many are the “excellent sheep” that William Deresiewicz has just written about and which you reviewed on these pages.

The thing that you all at the national papers don’t realize is that you can’t “get” the doctors without getting yourselves. You have brought down the medical profession – as Dr. Jauhar chronicles – but you have also brought on a form of medical holocaust in which the sickest will be allowed to die sooner than necessary because it’s more “cost effective” and a better use of resources for “population health” and promoting the RWJF’s “culture of health.”  You can file that under “unintended consequences.”

Coming soon to an urgent care center or hospital or primary care office near you might be the kind of care you have promoted all these years with articles like this but which fails you when you really need it.  You will then be like Charles Ornstein of ProPublica who just wrote about his using the “I am a reporter” trump card when dealing with his managed care insurer’s incomprehensible charges for a drug for his sick child. Maybe your “I am a reporter for the Wall Street Journal” or “I am an Editor with the Wall Street Journal” will save you or your aged sick parent. But don’t count on it. The system you have brought on features doctors whose primary allegiance is to some corporate bottom line. After all, they have big student loans to pay off, house payments to make, and wives who want to drive Mercedes and Jaguars.  In other words, you can’t trust doctors to do what’s best for you and your loved ones any more. They’re going to please the hospital administrators who own them.

In July, 1986, I was having dinner with the late journalist Harry Schwartz – who wrote for the NY Times for 29 years, had a PhD in economics, and was a long-time critic of managed care. He was helping me prepare for an appearance on “Good Morning America” debating the head of a state Medicaid managed care program. I asked Harry for a good, terse soundbite to respond to a question like, “Why can’t HMO doctors take good care of sick patients?” He threw back his head and laughed and roared, “They won’t let “em.”

Dr. Jauhar either hasn’t learned that lesson or won’t come clean with the American public. And you are complicit in not exposing that reality. “

The practice of medicine today is all about money, as in large amounts of capital, not doctors driving a new Mercedes. Those with large amounts of capital control the practice of medicine and I’m referring to big employers, big insurance companies, HMOs, big hospital corporations, places like Harvard – and not the much maligned doctors in private practice.

Doctors and patients were reduced to profit and loss centers a long time ago.

Dr. Jauhar, and the two Times’ book reviewers, don’t seem to understand that the same forces that bought off Congress a long time ago used that influence to induce Congress to  pass laws, rules and regulations and re-shape the courts to destroy the ability of doctors and patients to freely make decisions about medical care.

Dr. Jauhar’s simplistic advice to doctors to concentrate on helping people in need will be a lot more difficult to follow after the effects of his book further erode the public’s confidence in their doctors.

Health Care Competition Drives Prices Up Not Down

“Competition” in health care is supposed to drive prices down. That’s the way the media-anointed economists have been explaining it for the past 30 years or so. That’s part of the reason we have Obamacare, with its Accountable Care Organizations and hospitals now gobbling up doctors practices all over the country.

San Antonio has always been at the forefront of “free market reform. “ This is where Humana Chairman and former CEO Mike McCallister cut his teeth teaching doctors how managed care worked.

And this is where Physicians Who Care was founded to try to educate patients about how corporate health care worked.

So, it was with interest that I read two things this week that are related, but maybe not obviously so.

One was an article in San Antonio’s only newspaper, the Express News, a long time doctor bashing screed, unless it’s the University Health Science Center and its physicians, who can do no wrong.

Their brand of “competition” is financed by tax dollars, but that’s another story.

The page 1 article Wednesday, September 3, 2014 was about “Small firms feel pinch in Bexar.” Bexar (pronounced BEAR) is the county where San Antonio is located. The article told how small businesses in the San Antonio area have been “closing their doors at a higher rate than their peers in Texas and the nation – especially medical doctors…”

The Express News goes on to speculate that the Affordable Care Act, otherwise known as Obamacare, has caused doctors to go to larger medical groups. And hospitals in San Antonio have acquired many medical solo practices and medical groups, especially in high revenue generating specialties like cardiology.

Now here is where “competition” comes in. As all media must do, the Express News trots out an expert, in this case, the interim dean of the business school of Trinity University. He explains that doctors in private practice are finding it harder to survive. So far so good. Then, the Express News trots out “Federal Reserve economic policy advisor Keith Phillips to opine that “As new businesses are established, increased competition drives some businesses into the ground.”

While not directly referring to medical offices, Phillips’ and Butler’s comments taken together provide an interesting insight into the kind of competition in health care that is actually driving up prices to patients – er medical consumers – rather than lower such prices.

You get that insight from another public document filed in what many would call an obscure legal case in Idaho pertaining to the Federal Trade Commission’s attempt to stop a large hospital system from acquiring a large medical group. A trial in federal court led to a ruling that the hospital could not acquire the medical group because it would be anti-competitive. It would give the hospital and medical group a near monopoly in that section of Idaho and eastern Oregon.  The hospital has appealed the trial court ruling to the Ninth Federal Circuit Court of Appeals.

In response to that appeal, attorneys general from 16 states – Texas is not one of them – filed a truly remarkable legal brief. On page 4 of that brief, the 16 AGs state:

“Even among not-for-profit health care providers, the growth in economic power through acquisitions leads to price increases – sued to fund salary increases for the board or management, or yet more acquisitions – rather than more affordable patient care or an expansion of the charitable reach of that care.”            

Wow! There is the best explanation yet of how all these high falutin’ theories of health care “competition” actually work in the real world of overpaid hospital administrators with their boards of car dealers, home builders, and Junior Leaguers.

I don’t have a PhD in economics or a title from a fancy Ivy League college, but I do know much about history – especially the history of predatory practices of hospitals here in San Antonio and the corporate greed of managed care entities.

This kind of “competition” by owned doctors is leading more procedures at higher prices. Hospital owned doctors bill with added facility charges. And the doctors are expected to earn their high guaranteed salaries.

Dr. Steve Cohen and I have been trying to tell the media about what was coming since 1985. But the Express News and their colleagues in other forms of media didn’t want to hear about it. We were just rich greedy doctors who feared competition.

So, now I say to the reporters and editors at the Express News: Don’t take it from me. Read it in a brief filed in federal court by the attorneys general of California, Washington, Pennsylvania, Connecticut, Delaware, Illinois, Iowa, Kentucky, Maine, Maryland, Mississippi, Montana, Nevada, New Mexico, Oregon, and Tennessee.

We’ve got competition right here in River City, but it’s fixin’ to have the opposite effect of what the gurus have predicted. Who would have thunk that?

So, the Express News got their way: doctors abandoning private practice and going under the control of hospital administrators. But prices will go up. Is that an intended or unintended result?

 

Quality Problems with VA Medical Care

I get up early and usually watch MSNBC’s “Morning Joe” for want of anything better to do. It’s usually entertaining and I can switch back and forth to Fox and Friends to get conservative views of the news, too.

But one area where Morning Joe fails is its understanding of health care issues. Today’s show was a good case in point. Pundit Mike Barnicle was expounding on the VA political mess. Twice he offered his analysis that scheduling delays were a big problem but that “once you get there” the care is “remarkably good,” and “first rate.” Those pronouncements are totally wrong and not based on any understanding of what is wrong and has been wrong with the VA for a long time.

It is the quality of VA medical care that should be at issue. Yes, scheduling delays are bad as are the cover ups of changed and gamed record keeping and scheduling systems.  But what is really bad is how the quality of VA care has suffered.

You only have to look at lawsuits filed against the VA for medical malpractice to see how the VA has failed to promote a culture of quality medical care. Take the case of the late Christopher Anglesey, a 32 year old Army veteran with a history of traumatic brain injury and PTSD, who had been awarded a Bronze Star in Operation Iraqi Freedom. His wife and 5 small children filed a medical malpractice case after he died from a lethal cocktail of drugs given by doctors at the VA Hospital in Salt Lake City after he suffered a broken leg. http://www.deseretnews.com/article/705389413/Widow-of-decorated-Iraqi-vet-files-wrongful-death-suit-against-VA-hospital.html?pg=all

The VA settled the Anglesey case. But the case raises disturbing questions about how veterans get combinations of drugs – narcotics and other Central Nervous System and respiration depressing drugs – when there is a sophisticated VA computerized electronic medical record system that should warn doctors and pharmacists to not prescribe dangerous combinations of drugs.  You can find the expert reports in this case on PACER, the electronic record system for federal courts.

Part of the VA’s quality problem is related to its being a training ground for medical students and newly minted doctors. Almost every doctor trained in the U.S. has rotated through medical and surgical experiences at VA hospitals and clinics. My training included rotations at the Durham, N.C. and Houston V.A. hospitals. My first month of internship was spent at the Houston V.A. hospital on a pulmonary disease inpatient unit. There are few areas of medicine more complex than a ward full of veterans with severe COPD and other chronic diseases. For sure, that experience was the equivalent of being thrown into the ocean with heavy seas to learn how to swim. A Duke professor used to tell us in medical school that “It’s tough to kill people,” jokingly trying to reassure us about the dangerous mistakes medical trainees make, often in the initial few months of each training year which starts in July.  The good luck that patients need to survive trainee ignorance is especially needed at VA hospitals.

My own favorite VA “war story” ( And almost very doctor who has trained at a VA has a story or two or three.) involved the teaching imparted to me one morning at “Morning Report” at the Durham VA Hospital by the Chief of Medicine at the time, Dr. Wendell Rosse. Rosse was a distinguished hematologist. He heard my report about seeing a veteran with atypical chest pain in the Emergency Department the night before. I told how I had worked up the patient and determined the symptoms to be not related to his heart, and not be life-threatening, and had sent the man home to be later worked up as an outpatient. Rosse was quick to point out that in the future he wanted all such patients admitted, not for their safety, but because the Durham VA was coming up for some sort of budget review and he wanted the inpatient admission numbers pumped up to justify more money for the hospital. But that was way back in the 1970s long before the now popular “less is more” philosophy of doing as little as possible without getting sued mentality. I was, however, working on the team that had shown from Duke data that acute heart attacks could be treated with markedly reduced inpatient stays for uncomplicated patients. But Rosse’s directive to the trainees was a good example of how the VA budget process was manipulated independent of medical need.  Don’t get me wrong:  I am not criticizing the late Dr. Rosse. He was a dedicated teacher and researcher. But he was a product of the VA budgetary process that has been dysfunctional for a long time.

The best solution to the VA “crisis” is to give veterans vouchers and let them get more of their care in the private sector. It’s a “crisis” that’s been around for a long time.  But if the VA hospitals were shuttered, there would be increased pressure on the private sector and where would trainees get their hands on experience in how to care for patients? Someone has to be the “guinea pigs” for medical trainees. Veterans are used to meet that need, but nobody advertises it. There is a big medical literature on the issue of how well VA care stacks up with care in non-VA settings for things like cardiovascular care, organ transplantation and diabetes care. I will explore that topic in another blog. What concerns me is that those comparisons are mostly done by VA researchers and one wonders how independent and objective they really have been.

For now, I’ll just hit the mute button next time Mike Barnacle starts pontificating on health care topics or switch over to ESPN to watch the top plays of the day.

Veterans deserve more honest and informed advocacy for the severe problems that are plaguing the quality of VA health care. Mike Barnicle should stick to rooting for the Red Sox.

Or Barnicle and his producers could host a panel of VA doctor whistleblowers and hear about the real problems of VA health care.

In fairness to Barnicle, he’s not the only commentator claiming that VA care is good. The NY Times published an op– ed piece by a former VA doctor that made that same assertion. Here’s a letter I wrote to the Times which of course they did not publish:

Re: “Why I Blew the Whistle on the V.A.” NY Times op ed page A19, May 24, 2014

Dr. Foote asserts that the V.A. “does a very good job at providing chronic care…”

With respect to the management of chronic pain, that is not the case.

On October 10, 2013, the House Committee on Veterans’ Affairs Subcommittee on Health held a hearing on the misuse of narcotic painkillers by the V.A. in treating veterans with chronic pain.

Widows and veterans testified about the V.A.’s failing to abide by its own 2010 pain management clinical guidelines that resulted in patient deaths. Two physician whistleblowers testified about how V.A. administrators told them to prescribe narcotics against their better medical judgment. The House members, several of whom were also physicians, demanded answers from the V.A. in 30 days. Almost 5 months later, the V.A. came back to Congress and failed to answer important questions. This is not a problem of a “mismatch between the V.A.’s mission and its resources.”  This is a problem of V.A. administrators not being held accountable and being arrogant and feeling that they are untouchable. The V.A. has addicted thousands of veterans to narcotic painkillers. The V.A. has prescribed narcotic painkillers to thousands of veterans with sleep apnea which is in violation of their own written clinical guidelines.  You don’t need an extensive internal investigation to show this. It would be simple to write a program that looks at all veterans prescribed drugs like hydrocodone, oxycodone, and benzodiazepines and also look at all those with a diagnosis of sleep apnea. Those patients would need immediate scrutiny for their safety, and those who administered or caused to be administered these potentially lethal cocktails of drugs could be investigated and educated or held accountable.

The V.A. currently has all the resources it needs to investigate this outrageous patient safety problem of their own causing. But they lack the will to do so.    

The Making of ObamaCare

The following is a copy of a Letter to the Editor I sent to the Wall Street Journal about an article they published by Ezekiel Emanuel on Page C3 of the Review Section on March 8-9, 2014. The WSJ did not publish this letter, but it has points that need to be made.  BSM

03/08/2014

To the Editor:   Re: The Making of Obamacare, Review, page C3, March 8-9, 2014

It is fitting that the illustration you chose to accompany this piece by Dr. Emanuel features a caduceus rather than the rod of Aesculapius. The Caduceus, with two serpents surrounding a staff, was the symbol of the Greek god Hermes, who was associated for deception and thievery.  The rod of Aesculapius which has one snake surrounding a staff is the image most often associated with healing and is the image used by the American Medical Association.

Dr. Emanuel deserves the caduceus illustration for deceptively promoting bundled payments as superior to fee-for-service medicine. We have already tried lump sum payments in the form of capitated payments in the 1990s. That led to all sorts of abusive practices by HMOs and large doctor groups who cut corners to save a buck, with the media having a field day with stories of patient harm. Fee-for-service became plea for service.

Dr. Emanuel makes it sound like all the ivory tower theorists and politicians want to do is fix the price of procedures like hip replacement and pacemaker insertions. But he fails to disclose that real cost savings come from decreasing the volume of services to the aging Baby Boomers not by cutting prices. He deceives people into thinking that their political leaders are giving them a price break – something for nothing – when in fact what is actually happening is that doctors and patients are being herded into organizations facilitated by Obamacare that will in fact usher them out of this world sooner than necessary in the name of corporate greed.

If you think that the only procedures that will be cut are the “unnecessary” ones, think again. Ask Dr. Emanuel why his friends in HMOs and the insurance industry won’t make public their criteria for medically necessary care. After all, if they’ve all figured out the right way to practice medicine, publish the guidelines so everyone can benefit.

And if he were honest, Dr. Emanuel would tell the readers how many restaurants in the U.S. have fixed price menus rather than a al carte menus. The answer is very few. But he wants patients to have not only fixed prices, but narrow networks of doctors and hospitals, as in you can’t keep the doctor you like.

Deceptively, Dr. Emanuel says that the ACA ushered in only 10 demonstration projects of fixed prices. That is a lie. The ACA promoted accountable care organizations of which there are hundreds. These are de facto HMOs run mostly by large hospital systems where highly paid administrators tell salaried physicians how to practice medicine.

Whether in hospital run accountable care organizations, or in insurance company owned HMOs, the managing entity has the legal authority to tell doctors what is medically necessary and that is almost never disclosed to the patient.

Zeke Emanuel arrogantly thinks he knows the right way to practice medicine and is not bashful about imposing his will on our hapless population who think they’re getting something for nothing in Obamacare.

Unlike Greek mythology, when you’re dead from Dr. Zeke’s political machinations, no amount of touching you with a caduceus will bring you back to life. Dr. Emanuel’s painful prescription presages the death of American medicine and many innocent victims of his vast social experiment.

Gratuitous Doctor Bashing

This week’s award for the best doctor bashing compound sentence in a major national media so-called news article goes to USA TODAY for this gem on page 1 of the April 25-27 Weekend edition:

 “The 10 drug companies that make the most money from doctors using their products on Medicare patients spent more than $236 million to lobby Congress and the executive branch between 2009 and 2013, according to lobbying records compiled by the Center for Responsive Politics and new federal data.”

Wow! That’s going after several birds with one stone.

While I admire the journalistic effort to shine light on the real bad guys – Big drug companies, their lobbyists, and the bribes – er, contributions, sorry — they distribute at the congressional and executive levels, I fail to see why doctor bashing had to be included in the initial sentence.

Yes, doctors prescribe the drugs that USA TODAY is critical of – mainly Lucentis vs. Avastin ($2000 vs. $50 per injection) for macular degeneration. But those are the same two drugs the national media have been citing for years now. And they have used this issue to bash all doctors who care for Medicare patients, even the lowly primary care doctors who make nothing from Lucentis, while toiling in the trenches listening to a myriad of complaints while not having the time or the money to get to a Mercedes dealership to press their noses against the window and view the overpriced $60K Mercedes CLA 45 that USA TODAY features on page 4B of the Money Section.

But the real villains who allow this bribery to go on are members of Congress who take the contributions and protect the big drug companies.

USA TODAY could have asked why there is no competitive bidding for Medicare drugs?  And why did it take so long for there to be some competitive bidding for durable medical equipment, like the infamous seat lift chairs that I reported on for local TV news in the early 1990s?  Maybe USA TODAY would like to investigate that?

What is even more interesting is how the print edition of the story differs from the electronic version:

http://www.usatoday.com/story/news/nation-now/2014/04/24/drugmakers-lobbying-medicare-payments/8055901/

The electronic version is much longer and actually deals with some specific examples of drug company lobbying that might have increased costs to Medicare. Doctors were not involved in those political decisions. Those decisions were made by politicians and bureaucrats.

Yes, I know that doctors prescribe the drugs that make drug companies rich. With the exception of a few abusive eye MDs, most doctors don’t get rich prescribing brand name drugs.  USA TODAY should have constructed the lead sentence of the print version of the story this way:

“The 10 drug companies that make the most money from Medicare patients spent more than $236 million to lobby Congress and the executive branch between 2009 and 2013, according to lobbying records compiled by the Center for Responsive Politics and new federal data.”

Besides, it’s Medicare patients who USE the drug products. Its doctors who prescribe them, along with nurse practitioners and physician assistants.

The print article implies that there is wrong-doing in the Medicare program promoted by the lobbying efforts but doesn’t provide one shred of such evidence.  All the people who read USA TODAY while traveling and at hotels deserve the full story – free of doctor bashing.

Biased Reporting on Medicare Advantage Plans by the Chicago Tribune

The Chicago Tribune ran an article on 4/22/14 about the resignation of a top Medicare bureaucrat, Dr. Jonathan Blum.  According to reporter David Morgan and his editor Andrew Hay, Dr. Blum was responsible for a lot of reforms including “efforts to move the $635 billion healthcare program for the elderly and disabled away from costly fee-for-service medicine.” (my emphasis added)

I posted the following comment to the article on the Chicago Tribune’s Facebook page:

 Your biased reporting and editing calls fee-for-service practice “costly.” If that is so, then Medicare Advantage (Medicare HMO) care should be called “even more costly,” as numerous studies have shown it to cost from 11-22% more than comparable Medicare fee-for-service care. And that is why the Obama Administration tried to cut payments to Medicare HMO plans. But that didn’t work, no doubt due to heavy lobbying efforts.

It’s amazing that the reporter and his editor published such a biased comment, but it shows the true feelings of the media.  As I have said in these posts before, the national media believe with all their hearts that fee-for-service (“FFS”) medicine is the root of all evil in medicine. If only they could do away with FFS medicine, then they wouldn’t get any bills and they could afford a better lifestyle on their meager reporter’s salaries.

In writing such nonsense, reporters and editors not only show their biases, they also show their ignorance.

There is a mountain of published studies showing that Medicare HMOs – whatever they have been called for the last 30 years – have not saved taxpayers any money. In fact, they have always cost taxpayers more money than FFS medicine. Don’t take my word for it. Read all the studies – - starting with a Mathematica study in the 1990s. Here’s the link to the NY Times article from December 27, 1993:

http://www.nytimes.com/1993/12/27/us/medicare-to-stop-pushing-patients-to-enter-hmo-s.html

That article says the HMOs cost 5.7% more than FFS medicine. But more modern studies of the plans that were renamed “Advantage” showed them to be from 11-22% more costly.

And in another display of biased reporting, they are almost always referred to a “private plans.” The media know that people dislike HMOs. So they call these plans “private plans” so as not to engender dislike for what these arrangements really are: HMOs.

Taxpayer dollars have been paid to Medicare HMOs run by the likes of Humana and UnitedHealth Group (and prior to that Secure Horizons) to enrich the HMO executives and lobbyists who sell this stuff. Fortunes have been made gulling the public and Congress who has been only too happy to accept the re-cycled taxpayer dollars — now called political contributions — to stay in office and further screw the Medicare beneficiaries enrolled in these plans.

The enrollees, particularly in places like San Antonio, where there are a lot of poor people, think they are getting something for nothing. The politicians make them think they are getting “free” goodies that come from rich folks and particularly rich doctors who can no longer give them a bill.

But it has all been a scam.

Virtually every study done on the cost savings of Medicare HMOs show they are more costly than FFS Medicare.  But you can’t make them go away. The Wall Street Journal frequently editorializes that Medicare HMOs give patients more choices? Choices of what?  Gym memberships?  Certainly not doctors and national treatment centers. The narrow networks everybody is deriding as a bad part of Obamacare plans got their start with the narrow networks of Medicare HMOs.

Here’s my financial analysis pearl of the day: If you want to see if funding is going to be cut to Medicare Advantage HMOs, just look at the charts of the stocks of Humana ( symbol HUM) and UnitedHealth Group ( symbol UNH). As long as those stocks keep going up, you’ll know that funding to them is robust and the defunding called for by the ACA is not going to happen. You can at both of these stocks and see that their stock prices have been going up steadily since the passage of the ACA.

I would bet that Dr. Blum goes to work for a company that benefits from Medicare Advantage stock prices or the policies that promote Medicare managed care.  He certainly did a lot to enhance the value of the companies that sell those plans.