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Why Is Healthcare Reform Going So Badly?

11/23/2009

Because it's all about money! Healthcare won't get fixed as long as the stakeholders in healthcare with the biggest voice in its reform are the insurance and pharmaceutical industries, medical device makers, lawyers and others whose business thrives on the increasing healthcare expenditures of the American public.

What we have in American healthcare is a gravy train filled to the brim with tax dollars and premium payments generated from a series of skewed and irrational government tax codes and other assorted lobbyesque generated regulations that guarantee the only possible way to obtain healthcare in this country is through a system devoid of personal responsibility.

If only the people had the individual power to generate market forces in premium pricing through choice and responsibility. What a wonderful world this would be. I disagree quite frankly with one assertion made in the blog post above. Competition would reduce cost to the consumer and generate profit for the corporation. Both are healthy to the consumer because profit gives incentive to remain a viable and vibrant corporation.

What we have in private insurance is not capitalism. It is a series of state instituted monopolistic entities that have generated mafia like status in their ability to control prices to their advantage. Until capitalism is allowed to return to the insurance market, what we have is nothing more state sponsored economic terrorism.

Open up the market people. Make the insurance companies accountable to 300 million individual Americans and one million physicians, not a few thousand corporations who decide what plan is best for their employees based on the director of human resource's experience with her sister's, husband's mother in-law.

If you want insurance to work it must be accountable to the driving forces of capitalism on a grand scale. And that means giving Americans what they need at an affordable price or going away entirely. The problem with private insurance is not that they are profit driven entities. It's the lack of competition generated by government interference in the free market that prevents the profit from being obtained efficiently.

What the government won't tell you is that they fear private insurance success more than they do failure. For success makes those in government irrelevant. And irrelevance takes the money out of the power.

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Anna Deavere Smith’s “Let Me Down Easy”- A Must See!

11/16/2009

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Did any of you happen to see Bill Moyer’s Journal yesterday on PBS? If not, you owe it to yourself to go to the PBS web site located at http://www.pbs.org/moyers/journal/11132009/watch.html and watch his interview with Anna Deavere Smith, as she speaks about and introduces video excerpts of her one-woman show “Let Me Down Easy.”

The following is an excerpt from a recent NY Times theater review by Charles Isherwood:

“Even if you have already had your fill of heated debate about the crisis in American healthcare — informed, opinionated or just plain batty — do not go in fear of “Let Me Down Easy,” the new solo show from Anna Deavere Smith. The buzz words that have been filling the airwaves like swarms of gnats (“public option,” “death panels”) make no appearances in this engrossing collection of testimonials about life, death and the care of the ailing body.

True, Ms. Smith has collected some input on the state of the current system. She includes contributions from a rodeo bull rider with a cynical view of doctors and a medical school dean who argues that prime consideration must be given to end-of-life care. (Yep, it’s that freighted grandma issue.) But just as often she seeks answers to more open-ended questions about the power of the human body, its susceptibility to disease, and the divide between spirit and flesh that poses mysteries no one can really elucidate.

Unlike Ms. Smith’s acclaimed previous works, about the riots in Crown Heights, Brooklyn (“Fires in the Mirror”) and the racial unrest in Los Angeles after the Rodney King verdict (“Twilight: Los Angeles, 1992”), her new show is not tightly focused on a historical event.

Actually it is not particularly focused at all, though it is continually engaging. Instead of devising an organized primer on issues pertaining to health care in America, Ms. Smith has created a loosely framed but vivid compendium of life experienced at its extremes, drawn about equally from the suffering and the ministering sides of the story.

The first third of its 95-minute running time is largely taken up with attitudes toward the human body, and particularly the dedication of athletes who push against its limits. As always in her shows, Ms. Smith draws her texts verbatim from interviews she conducted herself, including pauses, repetitions, digressions and the occasional interruption for a cup of coffee or a ringing phone — details that add to the verisimilitude of the testimony.

The seven-time Tour de France winner Lance Armstrong speaks of his fight against cancer and how his natural competitiveness primed him for the battle: “The motivation is failure, ’cause failure’s death.” Then he turned around and used this souped-up ambition to return to cycling with more spirit than before: “Not that I thought I was gonna die if I lost the tour. But I certainly, I didn’t, I just didn’t want to face this, this, this demon called failure.”

The bull rider, Brent Williams, describes in gory detail the various predations he has subjected his body to, and how the doctors stitched him back up. He had his nose straightened after a fall without anesthetic so he could ride again that night. The heavyweight champion Michael Bentt recalls his brutal last bout, which put him in a coma for four days.

As the sports columnist Sally Jenkins notes, we prize athletes for their prowess and as symbols of the human ability to transcend life’s natural limits. The downside to this celebration of the superhuman is a denigration of the merely human.

In a rambling but funny monologue, the writer and activist Eve Ensler deplores the cultural pressure on women to simulate agelessness. “I think in this culture people don’t really die,” she cracks. “We’re all immortal here. We are all forever young here.”

As you may have gathered, Ms. Smith’s pool of participants is a little celebrity-centric. But as the show moves into more specific considerations of the state of health care, and later into meditations on death and disease, the balance tips in favor of nonboldfaced names.

Unnecessarily, we hear a breezy Lauren Hutton talking about how the Revlon chief Charles Revson opened doors to the best doctors in the city for her. More potently moving are the recollections of a physician working at a public hospital in New Orleans during the horrific aftermath of Hurricane Katrina. Her sorrowing description of the government’s failure to evacuate the suffering poor offers stark proof of the economic disparities endemic to the current system. Another funny-sad example of inequity comes courtesy of a patient at Yale-New Haven Hospital whose charts disappear — like so many others, a resident shruggingly notes — until it is discovered that she is the chairwoman of the medical school.

Under the direction of Leonard Foglia, Ms. Smith moves briskly among these personalities on a handsome circular set ringed by large mirrors, designed by Riccardo Hernandez. Ann Hould-Ward conceived the simple costumes that Ms. Smith employs to signal her transformations.

For the most part these are unnecessary. Ms. Smith is not the kind of performer who wholly disappears into the people she is portraying; she is too forceful a presence for that. Instead she channels their voices through her own, using the specifics of speech patterns more than any fancy vocal gymnastics to let us hear each as an individual.

The final segment of the show, concentrating on the struggle against fatal illnesses and the reality of death, is naturally the darkest and the most affecting. An expert in palliative care speaks of how we cope with dying much as we have faced life’s lesser calamities. “If we were angry, we’ll probably be angry,” he notes. “If we denied the whole thing, we probably will deny the whole thing.”

Proving the point, the former Texas governor Ann Richards remains a blunt-spoken optimist even as cancer comes to call. Also fighting cancer, the film critic Joel Siegel retains his humor and his stubborn nonbelief in a sympathetically intervening God. “I do not believe in a God who would in any way interact between me and my disease,” he says. “I’m very Jewish.” (Both Ms. Richards and Mr. Siegel eventually lost their battles.)

Intentionally or not, “Let Me Down Easy” seems to have several endings. Mr. Siegel could have sent us out on a mordantly funny note. The minister at the Memorial Church of Harvard, offering his views on the importance of accepting the fact of death (“Cherish the moment”), also seems a natural climax. His monologue is followed by a still more moving one from the director of an orphanage in South Africa, recalling the words she used to comfort an adolescent girl dying of AIDS.

And yet this heartbreaker is not the last word either. It almost seems Ms. Smith does not want to stop for death — like Emily Dickinson, and for that matter the rest of us.”

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Can Expert Panels Improve Healthcare?

11/10/2009

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We already have too many expert panels – guideline committees. They could improve healthcare if they followed the rules of proper guideline development. The key here is to not write guidelines unless the data is strong. We must avoid opinion based guidelines. We need well-balanced panels that include strong methodologists, generalists, ethicists and patient representatives.

This editorial points out some problems with expert panels – ‘Expert Panels’ Won’t Improve Health Care by Norbert Gleicher, MD, but I would argue that when done properly expert panels can provide some aid to practicing physicians. The author actually does explain the good as well as the bad:

“The idea of creating expert panels has a certain logic to it. After all, who is better qualified to determine best medical practices than medical experts? The medical field itself has been edging toward a similar approach in recent years with “evidence based medicine,” an approach that assumes it is possible to determine what works and what doesn’t by reviewing published medical literature.

Evidence-based medicine has some value, but it can provide misleading information. Determining which studies to review, for example, can introduce biases. Whether investigators accept published data at face value or repeat primary data analyses also matters. If the data in a published study were poorly analyzed or, for argument’s sake, completely invented, relying on it can lead to faulty conclusions. It’s an unfortunate reality, but our medical literature is significantly contaminated by poorly conducted studies, inappropriate statistical methodologies, and sometimes scientific fraud.

Of course evidence-based data can be useful. But I have seen firsthand how it can be dangerous too.

Consciously or not, those who provide the peer review for medical journals are influenced by whether the work they are reviewing will impact their standing in the medical community. This is a dilemma. The experts who serve as reviewers compete with the work they are reviewing. Leaders in every community, therefore, exert disproportional influence on what gets published. We expect reviewers to be objective and free of conflicts, but in truth, only rarely is that the case.

Albert Einstein once noted that “a foolish faith in authority is the worst enemy of truth.” At the moment, there isn’t an overreliance on expert panels in health care. Our system can therefore self-correct when experts lead us astray. This has given us the best medical care in the world, which is still envied by people from all over the world who face much more rigid, government-driven health care.”

I believe the biggest problem is in confusing guidelines and rules. We do need limited guidelines, we do not need rules. Expert panels can provide useful analyses, but too often do not. I would rather see government sponsored panels like the defunct AHCPR guideline panels, than the current rage of subspecialty organizations issuing guidelines and seemingly expecting generalists to “obey” their pronouncements.

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‘Going Dutch’ For Ideas On Healthcare Reform

11/6/2009

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There was a great article in the NY Times Sunday magazine recently entitled 'Going Dutch' about healthcare in the Netherlands. The ostensible focus is on the social welfare network of the state, and contrasting an American expat's experience there. One of the issues discussed is healthcare, a very timely topic as it relates to the United States. Below is an excerpt from that article:

"The Dutch healthcare system was drastically revamped in 2006, and its new incarnation has come in for a lot of international scrutiny. “The previous system was actually introduced in 1944 by the Germans, while they were paying our country a visit,” said Hans Hoogervorst, the former minister of public health who developed and implemented the new system three years ago. The old system involved a vast patchwork of insurers and depended on heavy government regulation to keep costs down. Hoogervorst — a conservative economist and devout believer in the powers of the free market — wanted to streamline and privatize the system, to offer consumers their choice of insurers and plans but also to ensure that certain conditions were maintained via regulation and oversight. It is illegal in the current system for an insurance company to refuse to accept a client, or to charge more for a client based on age or health. Where in the United States insurance companies try to wriggle out of covering chronically ill patients, in the Dutch system the government oversees a fund from which insurers that take on more high-cost clients can be compensated. It seems to work. A study by the Commonwealth Fund found that 54 percent of chronically ill patients in the United States avoided some form of medical attention in 2008 because of costs, while only 7 percent of chronically ill people in the Netherlands did so for financial reasons.

The Dutch are free-marketers, but they also have a keen sense of fairness. As Hoogervorst noted, “The average Dutch person finds it completely unacceptable that people with more money would get better healthcare.” The solution to balancing these opposing tendencies was to have one guaranteed base level of coverage in the new health scheme, to which people can add supplemental coverage that they pay extra for. Each insurance company offers its own packages of supplements.

Nobody thinks the Dutch healthcare system is perfect. Many people complain that the new insurance costs more than the old. “That’s true, but that’s because the old system just didn’t charge enough, so society ended up paying for it in other ways,” said Anais Rubingh, who works as a general practitioner in Amsterdam. The complaint I hear from some expat Americans is that while the Dutch system covers everyone, and does a good job with broken bones and ruptured appendixes, it falls behind American care when it comes to conditions that involve complicated procedures. Hoogervorst acknowledged this — to a point. “There is no doubt the U.S. has the best medical care in the world — for those who can pay the top prices,” he said. “I’m sure the top five percent of hospitals there are better than the top five percent here. But with that exception, I would say overall quality is the same in the two countries.”

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Four Solid Ways To Increase New Dental Patient Flow

11/3/2009

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There are certain necessary steps that need to be taken, in order to get all the new patients you could ever imagine. Take these steps and enjoy the ride.

There are a ZILLION ways to increase new patient flow. Not literally of course, but there are more ways than 20 pages of 12 point text can hold, let’s put it that way.

To have a steady flow of new patients ready, willing and able to pay your fees (and I hope your fees are HIGH so you actually enjoy practicing dentistry), you have to do what is often referred to as an economical, innovative, simultaneous and massive action.

You CANNOT do just one or two things at a time and expect to have more patients than you can handle. It doesn’t work that way. You have to be overwhelmed and wondering where to put those that are calling. You have to have an abundance of patients demanding your services. This happens when you get off your rusty dusty and DO/GET more than one way working for you. Preferably a half dozen or more since two or three will carry the weight/freight and deliver the large majority of those patients you need.

Here are four ways to increase new patient flow.

1. Free Standing Inserts: Once a month or more place a full-page, 8.5” × 11” sheet of paper inside your daily newspaper (almost ALWAYS on Tuesdays).

Every time you do this, you generate patients with a cost of $25 to $100 per patient. Can’t beat it. You always have an offer, testimonials, a great headline, a relevant photo, and so on. The ONLY thing you do is prepare an electronic file for the printing company you work with.

You send the electronic file to your printer. They print the inserts and deliver them to the newspaper. The newspaper then inserts it on the day of their choice. You generally have 15,000 or so inserted into the newspaper for a cost of about $0.08 each. WHERE else can you get 15,000 flyers in the hands of people who like to read?

Your local paper is about one of your only options. To me, it’s one of the best values in advertising today.

2. Newsletters: In my world, patient newsletters are the easiest way to generate new patient referrals without any effort on your part. Referrals are the best new patients you can ask for, and we all know that already.

They feel like they already have an established relationship with you and trust you. You can’t BUY that kind of respect and trust and it’s important you respect it and use it to your advantage by encouraging your patients to refer more often and reward them and recognize them when they DO refer. Positive reinforcement, right?

In your newsletter, there are very specific actions you should be taking to generate the best return on your investment. Your results will be spectacular, especially considering how little it requires from you and your team (a trivial few minutes each month spent by an appointed team member).

Plan and budget for spending each and every month to KEEP your best patients in your practice. If you don’t they WILL go somewhere else. This is just one of the very important contact points to keep going 12 months in a row, year-long.

3. Referral Letters: I like referral letters. They are easy, to the point, and frankly, they work. Three of my clients sent out one such referral letter to all of their A & B patients, asking gently, for their assistance this summer in keeping them busy (the best story to tell is the truth, right?). This is cheap to do. It’s straightforward and can be done in a matter of minutes by one of your team members.

4. Endorsed Mailings: These are really easy, again, no-brainers. Here’s the principle behind them - You find another local business person that has customers you’d like to have since they could easily mimic the customers you already have.

If all of your patients are females age 40 to 50 and without kids and there’s a divorce attorney in town that specializes in representing women in that age bracket in divorce cases without kids, there’s a match, right? So you simply ask the attorney to lunch, let them know you have the kind of clients each other wants and see if you can work out a joint marketing effort. If you both are doing newsletter article submission, it’s real easy and you can just insert a flyer (your free-standing insert from above should work). This kind of thing works well with high-end car dealers as well.

One of my local clients does this once a year with the local Mercedes dealership. They ALWAYS pick up some great patients at or near ZERO cost and they are great folks especially since they like to spoil themselves!

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