Wednesday, March 29, 2006

Vox Populi

The new Gallup poll says it all.

What's the number one concern of American voters? Is it the War on Terra? Is it saving the blastocysts, or the brain dead? Is it keeping homosexuals in the closet? Is it illegal immigration, or crime, or drugs, or even social security? Nope. It's

The availability and affordability of healthcare

68% of respondent say they worry about that "a great deal," up from 60% last year, and leading the list of voter worries not by a little, but a lot. Social security comes in second, at 51%. And guess what? Democrats worry about it the most, but it is the leading concern of Republicans and independents as well.

So then, who should win the November election? If we can avoid getting drawn into a lengthy discussion about The 10 Commandments, flag burning, the homosexual agenda, and who eats brie, I think the answer is obvious.

But then, if the Democrats reclaim Congress, will they stop listening to the voters, and just listen to the lobbyists? Watch this space.

Cross posted from Stayin' Alive

Thursday, March 23, 2006

Inequality and Health Care

Our second guest post is from Systemdoc. Thanks for sending it in, and we're always looking for more good information and analysis like this. I've done a little light editing and made a couple of enhancements to make this blog-friendly -- that's a free service you get here, and only here. I hope Systemdoc doesn't mind. My interpolation in italics.

-- Cervantes

Starting points in the daily media stream of information about the “health care industry” - comments on the integration of the US health care system into the global financial system – i.e. the “dis-linkage” of health care transactions from any human interaction that has local, community-based accountability.

First, this from AMA Medical News. It's subscription only, but AMA members can read this here.

March 6, 2006
Health plans make more, spend less in 2005
By Jonathan G. Bethely

If physicians needed any more indication of tightening reimbursement, how about this - not only did profits for the biggest health plans go up last year, but those plans also continued to cut the percentage of revenue they spend on care.

The medical-cost ratio - also called the medical-loss ratio or medical-care ratio - is the key number for health plans in terms of their level of profitability. That ratio, simply, is the percentage of dollars the companies spend on health care.

Whereas 10 years ago many plans had medical-cost ratios in the high 80s or 90s, now the highest percentage among large, publicly traded health insurers is Health Net, at 83.9%. Aetna, which had a medical-cost ratio well into the 90s when CEO John Rowe, MD, took over in 2000, recorded a ratio of 76.9% in 2005, Dr. Rowe's final full year before his retirement. That was the lowest medical-cost ratio for the nation's largest publicly traded plans.

Medical-loss ratios for 2005 (Source: Company 10-K, year-end filings with the Securities and Exchange Commission):

76.9% - Aetna
82.3% - Cigna
83.9% - Health Net
83.2% - Humana
78.6% - UnitedHealth Group
80.6% - WellPoint

And this tidbit taken from Don McCane’s daily internet report from Physicians for national health insurance points to the accelerating nature of the financial concentration of dollars/capital in the private portion of the US health care system:

[O]f course, it is estimated that about 60% of the actual health care dollars are provided by public payors, e.g. Medicare. (source: Woolhander and Himmelstein: Paying for National Health Insurance- And Not Getting It – Health Affairs: July/August 2002 pp 88-96)

So we have an example of how the publicly provided dollars/resources are taken up by for profit entities, with the services to the population restricted. With all this consolidation, the “non-profit” sector has been pushed my economic forces to emulate the for-profit sector.

The Center for Health Systems Change (funded by the RWJ Foundation, and is affiliated with Mathematica Policy Research) conducted a review of hospital billing practices -this review had been triggered by the public scrutiny of non-profit hospitals’ billing and collection practices, which, reportedly, had included putting liens on the homes of patients who had not been able to pay their hospital bills.

This report presents the sympathetic view toward the hospitals, that they had restricted some of their more aggressive collection practices, in response to the public outcry/scrutiny, but does make it clear that the public policy/political economy environment is driving them to try to collect unpaid billings from the uninsured. My own sense is that this progressive inequality in the larger US political economy is generating pressures on the health care “system” that lead to increasingly unjust practices – which, eventually, will lead to political unrest.

However, it may be that the ecological pattern of “punctuated equilibrium” will take over, with a period of outright chaos in the us health care sector, with the likely occurrence of the bankrupting of many community-based institutions such as hospitals and medical practices.

The collapse will have to take down some of this institutions before real health care reform, or the return of the "Hippocratic" physician - there is simply too much inequality in the health care political economy, with the "non-profit" hospitals, which even include the catholic church-owned hospitals, going after the meager assets of poor people, who, in fact, are charged higher prices than patients covered by the for-profit insurers. Certainly, in 10 years time, the academics will be writing about how unstable this current set of arrangements turned out to be.

Post by Systemdoc

Sunday, March 19, 2006

How Much of Our Health Do We Really Control?

The topic of how much of our health that we really control is, for me, probably one of the most difficult concepts that I will ever write about on this blog. Since Medical School in the late sixties up to the present I struggle with this central issue. I have concluded there are no easy answers now or likely ever? So I invite lots of dialogue on this from you.

I became interested in this issue because of my interest in psychiatry (never became a psychiatrist) , mind-body medicine , and more recently consumerism in medicine. Issues surrounding patient dependency on "MDieties" and the evils of excessive paternalism always intrigued me. Yet to this day, I remain plagued-almost haunted- by the notion that, as a doctor, my first moral principle was beneficence- to actively do good for my patients- to intervene on their behalf using my technical skill and knowledge that they could never hope to possess?

I scoured the medical literature for evidence on what % of illness was self induced through individual or collective human behaviors verses the roles of genetics.?I became interested in the psychology/sociology of accidents - still believing today that most are avoidable. I became interested in issues surrounding the environment and workplace (my chosen specialty) and how much control especially the disenfranchised really had over this?

This led to my interest in the fundamental dilemma of self- determination verses fatalism or pre-ordination and its association with belief in God verses existential self.

On a more practical note I studied the concept of Health Locus of Control (HLOC) a theory developed in @ 1976 which sought to quantify how much an individual believed health was under their own control (see

I read the late Susan Sontag's book Illness as a Metaphor (1978) where she chastised the mind- body movement accusing it of "affirming the primacy of secular spirit over matter" and inducing guilt in those who contracted cancer for example- the disease which ultimately took her life too soon! Yet I personally think Sontag was wrong in her indictment of mind-body.

Now we have consumerism in medicine which is encouraging patients to become educated, to ask questions of their doctors (see Cervantes Stayin Alive blog-Tues March 14-"Don't Be Afraid to Ask Questions") and to become co-decision makers with their doctors. This latter point is a huge tectonic shift in the heretofore paternalistic doctor-patient relationship.

Here is where I personally stand today. I like the model of the doctor as a the teacher. To me the best medicine of all is "helping people become themselves". I loathe the concept of victimhood. Yet, in the end, genetics is real, viruses and bacteria are real, environmental and workplace biological insults are real, natural and man-made catastrophies are real , some accidents I suppose just "happen", and certainly social injustice is VERY real.

When I consider the above external realities my ideas about helping my patients achieve "the gift of themselves" yields to my sense of moral obligation as a physician to offer the hand of benevolent paternalistic intervention to my patients to the best of my abilities with the knowledge and skills that contemporary western medical education and my years of practice have afforded me.

Please let me hear from you. I really need your input, your stories, your hopes your fears on this topic of importance to all of us.Thanks

Thursday, March 09, 2006

NIH Director Calls Curative Model of Medical Practice Unsustainable

Surely I must be dreaming- please someone pinch me!

Because in a remarkable interview by Barbara Culliton , Deputy Editor of Health Affairs of the Director of the US National Institutes of Health (NIH) Elias Zerhouni, MD said that the current curative model of US Medical practice is unsustainable. Published today on the Health Affairs website .Zerhouni sees his job at NIH , probably the most prestigious voice for bio- medical research worldwide, as one of "provocateur, not a manager of the status quo". He also emphasizes, as I have been, that the future of medicine be much more interdisciplinary although, unlike my own emphasis on fully integrating and leveraging bio-medicine with sociology, psychology, and theology (see ), Zerhouni references the need for bio-medicine to shake hands with nanotechnology, sytems biology, and- get this folks- "openness to radical ideas" with the hope that NIH dollars will be spent more wisely and have a cumulative effect on population heath. Yes, you heard me- population health!

While he sees value in electronic medical records technology and even national health insurance , Dr. Zerhouni says these could help reduce medical costs but only at the margins. Zerhouni believes rather that the practice of medicine needs to be fundamentally altered.

This remarkable interview of an obviously creative and couragoeus bio-medical leader is very good news for those of us who believe that more incrementalism in US Health Care System reform is a recipe for failure and also for those of us who believe in the imperative for early disease detection, chronic disease management and best of all primary disease prevention.

My personal Rx for american citizens from a Doc like me is perhaps even more radical?- Meaningful, safe and healthy jobs for all American citizens who are able to contribute and compassionate healthcare for those fellow citizens who are unable to engage in work.

Back to my opening comment on this post. Please e-pinch me. I need to validate that I read this interview while not dreaming. Be well all - better days-they are a'comin! Maybe sooner than we think?

Friday, March 03, 2006

Governors Meeting Theme in DC - Health Care???

From last Saturday Feb 25 to this Tuesday Feb 28 our nation's Governors (28 Pubs/22 Dems) descended on Washington DC to hold their winter NGA=National Governors Association meeting. Chaired by Mike Huckabee -Rep from Arkansas, who was even interviewed by Sesame Street characters Elmo and Rosita, believe it or not the meeting's theme was Healthy America? Yet competing legitimate interests like the war, homeland security , katrina, the general economy and a lot of back room/hallway corridor worry-chatter from Republicans about losing in this November elections unless they rapidly bail on a failed presidency, still seemed to dominate the headlines.

Needless to say much was said about health care at least at the fringes of our nation's health care crisis. Gov. Huckabee ,to his credit, is promoting wellness in his home state of Arkansas and, as Chairman of the NGA, set the Healthy America theme for the conference. In his home state Huckabee, a young Republican, has created ARKids which provides greater healthcare access to tens of thousands of Arkansas kids and is leading a ballot initiative to devote all of Arkansas' tobacco settlement money to improve the health of all Arkansans

The opening plenary session, "Creating Healthy States," featured a keynote address by U.S. Secretary of Health and Human Services Michael O. Leavitt. Also Dr. David Katz, Yale School of Public Health, also spoke at the Saturday afternoon session."Nearly 129 million adults in the United States are overweight; of these, more than 60 million are obese and 9 million are severely obese. Excess weight is an indicator of poor health habits- such as poor nutrition and lack of physical activity- known to cause or worsen chronic conditions such as diabetes and heart disease. When combined with tobacco use, these health habits are the leading cause of preventable death in the United States," said Gov. Huckabee. "These trends threaten the health of individual Americans and the American economy. We already pay more for health care than people in other Western nations. If we continue to tax our health care systems with chronic conditions, the system will worsen." Wow you would think they might have even been listening to my friend Dr Michael O'Donnell, our nation's leading advocate of Health Promotion or reading his political advocacy website, at .The plenary session on Sunday afternoon, "A Culture of Wellness: Healthy Messages" opened with a keynote address by Lee Scott, president and CEO of Wal-Mart Stores, Inc. (ouch! to that hypocrisy!) Following the address, CNN's Dr. Sanjay Gupta moderated a panel discussion focused on delivering healthy messages. Panelists Judy Harris, president and CEO of Channel One; Jennifer Kotler, director of research at Sesame Workshop; and Marva Smalls, executive vice president of public affairs and chief of staff for Nickelodeon Networks shared their experience with evidence-based messages that have proven compelling to the public-particularly those messages directed toward children, youth and their parents

Even former fast food eating-post coronary artery bypass surgery(Sept 04)- former President Bill Clinton spoke on the merits of a better health habits warning the governors that failure to change the nations eating habits will weaken the economy and threaten the lives of its children. Bubba said "We have a huge cultural problem and unless we change it our children may grow up to be the first generation with shorter lifespans than we had!"

Meanwhile head of the DGA= Democratic Governors Association Gov. Bill Richardson from New Mexico, our nations only Hispanic Governor, under the DGA tagline "Won't Wait for 08" is taking some good shots at the President and Dr. Frist for the botched Medicare prescription drug plan and draconian and cruel Medicaid cuts to the states. (more on that topic in my next post)

My question is this? - Where are the powerful Governors from big and powerful states from NewYork, Massachusetts, Pennsylvania, Florida, Michigan, Texas and California on Health Care Reform? With their campaign funding a pockets lined with Big Pharma, Big Hospitals, the AMA and Big Insurance industry $ I think I know? Alas they are not talkin too much about health care reform lest they anger their vested interest funders?

In my recent previous posts on this blog I highlight two former Governors who have the right stuff and right ideas on Health Care. They understand it is far too late for incrementalism. Namely former Governors Richard Lamm of Colorado and John Kitzhaber of Oregon. (see previous posts)

Ok -all 50 state Governors - you talked good game on health care at your fancy meeting. Now get some serious legislation through your states and through bottom up pressure influence the national agenda. The DEM Govs are painfully correct- We "can't wait for 08"

Our President Mr. Bush, Dr. Frist and friends are in "critical condition" on this issue of great importance to all Americans-embarassingly and tragically so.