It’s my pleasure this week to welcome a guest post from Dr. Vance Harris, a family doctor who practices in Redding, California.  Dr. Harris makes some excellent observations about two aspects of ObamaCare related to expanding the role of nurse practitioners.

The first is that giving NPs the privileges and responsibilities of actual physicians will somehow magically be separable from having them take on many of the same characteristics that our political Leaders are so quick to criticize in doctors.  These include having to practice expensive defensive medicine, becoming the object of politically-inspired suspicion and fear, and havingthe audacity to ask to be paid for their work.  What medically unsophisticated supporters of government-guided healthcare like Peter Orzag seem to miss, is that people in healthcare behave the way they do because of incentives and disincentives.  If you place different sets of faces into the same dysfuntional situation, they will tend to take on the same business characteristics as those they are replacing.

The second aspect is the blind assumption that, because NPs have lower nominal salaries than physicians, they cost less to use.  This is the sort of basic mistake that people make all the time with respect to medicine – they miss the concept of economic productivity.  If you call a nurse a doctor, that doesn’t mean that he or she will perform like a doctor.  Their education and training is very different.  Why would you expect that they will be equally expert, efficient or versatile in a physician-type clinical practice where anything and everything can come through the door?

I also wanted to take this opportunity to salute Dr. Jame Gaulte and his retired doc’s blog for his recent post entitled:

ACO and HMO, A distinction with or with/out a difference – Are ACOs an example of Underware Gnome Economics?

You have to love posts like this that are both humorous and brutally accurate.

This is a special post, because it allows you and yours to do something immediate, direct and positive to support the future of patient- and physician-oriented healthcare in this country.  We don’t get a chance like this very often.  You must vote before polls close on Sunday, February 14th!

It's hard to tell, but I think this guy might be wearing a white coat and carrying a medical bag...

If you don’t read unfashionably named Covert Rationing Blog (http://covertrationingblog.com/), you should.  This regular column is the work of Dr. Richard Fogoros, aka “DrRich”, a former cardiac electrophysiologist* who writes some of the most illuminating and insightful articles on healthcare in America today.  (Full disclosure – I’ve never met or actually spoken with the guy, he doesn’t pay me, and we’re not related.)

Dr. Rich’s posts are always painstakingly researched and often very funny.  More importantly, every one is written from the old-fashioned perspective that what really matters in healthcare is the integrity and utility of the doctor-patient relationship.  This is the concept that, when you’re sick, your doctor’s first and foremost loyalty should be to giving you the best and most honest medical advice they can muster; even if that medical advice is not in the best interest of your insurance company, the pharmaceutical industry, the government or anyone else with their own political or economic agenda.  In this view, your doctor is your personal medical defender.  After all when you’re sick and feeling crappy, you’re in no position to defend yourself, and your family frequently doesn’t have the medical or bureaucratic expertise to do so.

Why is the preservation of the doctor-patient relationship so important?  Because without it what happens to you as a patient is not what’s best for you – it’s what’s best for someone else.  And frequently, that someone else couldn’t care less about what’s best for you.  Governments, corporations and panels of experts don’t necessarily care whether you live, whether you die, or whether your physical and mental condition will allow you lead a worthwhile life.  Their realm lies in numbers, not in individuals.  It’s that simple.

Powerful and persistent attempts to erode the physician-patient relationship are a big part of why we’re currently on the Road to Hellth, and not the road to health in the United States, the United Kingdom and many other countries.

This is our chance to fight back.

Dr. Rich’s blog has been nominated for an award for the Best Health Policy/Ethics Blog on the Internet.  His chief competitor is the blog of the massive and politically powerful ACP – the American College of Physicians.  The most important difference between these two competitors is their attitude toward the physician-patient relationship.  The ACP has decided to endorse a “new set of ethics” in which “social justice” considerations (whatever the hell they are), should be taken into account along with the personal welfare of the patient when making medical decisions and dispensing medical advice.  Specifically, physicians should engage in “parsimonious care”, that is designed to minimize the use of medical resources and “ensure that resources are equitably available”.

To put it bluntly, the ACP is saying that when you’re lying there with a potentially fatal or crippling condition, your doctor has an obligation to think not only about what’s best for you, but also about what’s best for “society” in terms of what tests to perform, what medications to prescribe and what procedures to undertake.  They don’t actually say who actually gets to dictate the needs of “society”, but it’s a reasonable guess that your insurance company, government regulators, Medicare, the AMA or ACP, or some other “official” entity will be making the call.

“Normally Mr. Jones, I’d recommend that you get a CT or MRI test to make sure that you aren’t having a stroke or a tumor that we would treat immediately, but a ‘panel of experts’ has decided that it’s best for society that we order these tests parsimoniously.  So I’m going to have to think about this one for a while.  I’m sure you understand.  Tell me if you develop any further weakness and we’ll reconsider at some point in the future.”

I would strongly encourage you to read Dr. Rich’s discussions of these differences in perspective and their implications here, here, here and here.  I would point you to the ACP’s responses to Dr. Rich’s arguments, but they’ve declined to publish any on their own websites.

If you care about the future of healthcare and the physician-patient relationship, I strongly encourage you to take 15 seconds right now and vote with your mouse button. Here’s how:

1.  Go to: http://www.medgadget.com/archives/2010/01/the_2009_medical_weblog_awards_the_polls_are_open.html

2.  Scoll down the page to “Best Health Policies/Ethics Weblog”.

3.  Click on the link where it says “Please vote here…”

4.  Cast your vote for The Covert Rationing Blog

This may seem like a small thing, but much is at stake.  Virtually all of us, and our loved ones, will be patients at some point in our lives.  When that time comes will our doctor be advocating for us, or for some other nameless, faceless “societal good”?  There are far better ways to ensure the efficient use of scarce resources in healthcare without further degrading the physician-patient relationship.

Thanks for reading.  We now return you to your regularly scheduled life.

* A cardiac eletrophysiologist is a heart doctor who specializes in the cause and treatment of irregular heart rhythms.  Having dealt with many of these cases as an internist, I can tell you that it can be a very intense and nerve-wracking pursuit.

In our last post with this title, we began to explore how the conditions under which drinking water would be produced, distributed and paid for in the United States if it were treated it the same way in which we treated healthcare goods and services.  The purpose of this exercise is to try to separate the spin and hogwash surrounding healthcare from the simple reality of how we go about allocating healthcare as a scarce, finite resource.

As we begin our saga, water supplies are fragmented both locally and nationally.  Each state has completely different water quality and process requirements, as well as different licensure requirements for water technicians.  This makes it difficult and expensive to transport water across state lines or move water workers from state to state.

For reasons that no one can remember, most people have their water purchased for them by their employer.  Anyone who loses their job has to buy water directly, and at a much higher price.

For its part, the federal government has greatly increased the complexity of water supply, purchasing and utilization.  Through the Center for Water Services’ (CWS) “Watercare”, “Watercaid”, and “TRIWATER” programs, the federal government purchases water on behalf of those 65 or older, the poor  and military dependents.  The federal government fixes the price that vendors are allowed to charge for water delivered to these populations, and these prices are often below the actual cost of the water delivered.  To make up the difference, vendors are forced to charge higher prices to all of their other customers.  As the government reduces its reimbursements to providers each year, water rates for the remaining private customers climb steadily – imposing great financial stress on businesses and families.  Because they are losing money on the elderly and the poor, fewer and fewer providers are willing and able to sell water to these customers each year.  New entrants into the Watercare and Watercaid programs often have a hard time finding supplies.

The feds have also heavily regulated virtually all aspects of water delivery, and has created large numbers of rules, commissions, panels and other bureaucracies in an attempt to track, control and allocate water use throughout the nation.  For example,  suppliers must file detailed reports about their delivery of water to Watercare customers, including the amount of water, the time delivered, documentation proving delivery and what the water was used for.  In an attempt to limit climbing water expenditures, suppliers are expected to bill the government for water only if it will be used “cost-effectively” by Watercare recipients.  New rules and guidelines for what constitutes effective water use are published all the time (e.g., only one bath per customer per day is allowed unless the water supplier can prove that the customer was so subsequently soiled as to cause personal or public harm).  Billing the government for water that does not meet “approved use” criteria is a form of fraud, punishable by fines or jail time.  One result is that water suppliers gradually become paranoid and strive to deliver as little water to their customers as possible, even at the risk of depriving people of water that would otherwise be of great help to them.

What do you think? Should regulators approve this use of a scarce resource?

Finally, the federal government has begun to insist that water suppliers use “water information technology”.  These computerized record keeping systems are expensive, difficult to use and reduce the work efficiency of water suppliers substantially, but they keep detailed track of every drop of water given to every customer, and what it was used for, in real time.  Since this information can now be tracked and audited, regulators insist that suppliers report on various “water utilization quality parameters”, and threaten to reduce payments based upon whether suppliers have allowed water to be used in “undesirable” ways.

While we haven’t even begun to discuss “water reform”, it’s already possible to draw some conclusions  about this particular way of doing business.

Only an idiot or a saboteur would deliberately design, preserve and add onto a system this complex and  poorly regulated.  Compare this to the water system that you currently have in your community.  How much would your water cost if it were subjected to this sort of administrative overhead and regulatory complexity?America’s current healthcare system wastes 25% of total healthcare expenditures on excess administrative and regulatory overhead.  We’re not talking about your routine, normal everyday administrative expenses here.  These are excess administrative expenses – administrative overhead costs that go above and beyond those that are normally incurred by the healthcare systems of other developed countries.  To put this in perspective, it means that we are spending nearly $600 billion of healthcare dollars each and every year for goods and services that do not produce a single medical benefit.  Much of this waste is literally mandated by the state and federal governments that are forking out many of these healthcare dollars.
Despite the many benefits of free-market economics, market forces are effectively prohibited from operating in the system that we’ve described. Because the prices that most providers can charge are fixed by public and private insurers and the prices that many patients pay are highly regulated, there is essentially no opportunity to optimize the distribution or delivery of care by using the invisible hand of the market.  For all practical purposes this leaves us with a “command economy” in healthcare, where the inherent supply and demand for services is set by bureaucrats and regulators.  This is not particularly different from the way resources were allocated in the old Soviet Union.  The only real difference is a matter of degree.This is a problem because a market-based distribution of resources is generally far more efficient and less expensive than command-based distribution.  Having bureaucrats divvy things up generally produces the wrong amounts of the wrong things, and sends them to the wrong people.  It doesn’t work for the production and distribution of food, clothing, shelter or education.  Why would anyone expect it to work for healthcare?
Decisions about the use of resources like information technology are not arising from the needs of providers and customers, but from an unaccountable desire by regulators and special interests to actively regulate and control things. This pervasive sense that regulators can “do it better” is strange because it is practically unique to healthcare.  If these technologies truly benefitted healthcare providers and their patients, they would buy and adopt them themselves.  You don’t see the government mandating the use specific types of computer software in any other business.  We’ll talk more about this in future posts.

No rational person with the slightest knowledge of economics would ever propose that we allocate and regulate the production and distribution of water as we have done for healthcare.  Yet one can certainly argue that access to clean potable water is just as important than access to medical services.  Are healthcare services substantially more elaborate, diverse and complex when compared to water?  Of course they are, but the basic principles involved in the efficient and production will be the same for any scarce and finite resource.

In our next installment, we’ll look at the “reforms” that have been proposed by the President and Congress for healthcare, and ask if they would make sense as a means of improving the hypothetical water system we’ve described.

By now it’s clear that the 2,000-page House and Senate healthcare reform bills promoted by President Obama are unlikely to be passed anytime soon – at least in their current form.  Those of you overseas who may be unfamiliar with the American legislative process will have a hard time appreciating just how amazing this is.  Members of the Democratic Party had everything going for them – huge majorities in both houses of Congress, the vigorous support of a popular president, political momentum and the genuine best wishes of tens of millions of Americans.  To have the proposals fail in spite of all of these advantages is frankly astonishing.

Nevertheless, President Obama and his colleagues are undaunted.  Addressing a gathering of Senate Democrats recently, he exhorted them to “finish the job”.  And although he’s scheduled a televised “discussion” with Republicans to hear their ideas for reform, the President has already ruled out the idea of backtracking on the legislative proposals already passed.  (This makes one wonder just a little about how seriously the Democrats will consider ideas that may conflict with those they’ve already decided upon.)

How one might brand the typical discussion of “healthcare reform in politics and the media...

However the real question we should be asking is whether this particular “job” is one worth finishing.  History is full of dumb ideas that would have been best abandoned in the planning stages.  The Maginot Line, the Tacoma Narrows Bridge, and the conflict in Vietnam all spring to mind.  So we should perhaps take the time to ask a few key questions – questions that were apparently never asked in the closed-door rush to pass this legislation.  Does the general approach that Congress and the President have proposed make medical and economic sense relative to the problems at hand?  Does it pass the sniff test?  Is it reasonably fair?  And as Abraham Lincoln might have asked, “Can any such healthcare strategy, so conceived and so dedicated, long endure?”

Ironically, perhaps the best way to answer these questions is to pretend we’re not talking about healthcare at all.

You see, any important topic that gets too much time in the American spotlight quickly becomes politicized, emotionally charged, dumbed down and “spun”.  The end result is usually a meaningless discussion; one  filled with buzzwords and pundits, but little understanding or rational thought.  “Environmentalism” is a good example.  As originally conceived, it has real meaning.  Being environmentally responsible meant doing things that would truly benefit the natural environment.  But just add politics, emotions, spin and oversimplification and voila!  You’ve got “green”.  Being “green” comes complete with a wide variety of deceptive or useless terms like “clean coal technology”, “all natural arsenic”, and “organic cigarettes”.  In the case of environmentalism this process even has a name: “greenwashing”.

Healthcare is no different.  Once upon a time we would talk about “medical care”, “doctors”, “nurse” , “patients” and everyone pretty much knew what those things meant.  Now when you hear pundits and politicians talking about “healthcare”, “providers”, “managed care”, “quality care”, “rationing” and even “healthcare reform” there’s an excellent chance that none of them will even agree on definitions.  Apples are routinely compared with oranges.  Our national discussion about American healthcare has been thoroughly hogwashed.

One way around this is to think about the problem in terms of something else. Something simple, valuable and finite, but conceptually concrete.  You see, what we’re really talking about here is how our Leaders are proposing to allocate, use and pay for a finite resource.  When evaluating proposals like this it really doesn’t much matter whether that resource consists of physician time, electricity or education – the basic approach should be rational, fair, consistent and economically sustainable.

So for the purposes of this discussion, let’s think about drinking water.

Suppose for a moment that the U.S. did not already have relatively universal access to clean drinking water.  What if our state and federal governments applied the same rules, regulations and strategies to drinking water that they’ve applied to healthcare.  What would that look like?  Would anyone find this reasonable?

A patchwork system of water supply (similar to the patchwork system of American healthcare) would look considerably different from what we have now.  Large companies such as Coca Cola and Pepsico would do a massive business in bottled water and beverages – perhaps ten times more than they do today.  Other suppliers would sell water filtration systems to private homes, making it a several hundred billion dollar per year business.  Each of these entities would constitute massive special interests intent on preserving the status quo.  Great gaps would exist between water “have” and “have-not” people and communities. Many individuals and organization will claim that access to clean water is a “right”, regardless of ability to pay.

Now what would happen if our government and society chose to manage water the same way we currently manage healthcare?

We’ll explore this in our next post.