The following was sent today to several Senators and Congressmen:
June 17, 2009
Dear Senator ,
I am writing your office again to stress several issues which I believe you should consider as the many health care bills seem to be reaching resolution. The following are several points which have arisen as I have spoken with a great many physicians around New Jersey, New York, Massachusetts and New Hampshire. There seems to be a consensus amongst many practicing physicians that they may just become victims of an ever costly and oppressive health care regime run by Washington. I believe that in my conversations there is a great level of demoralization amongst the professionals who feel totally helpless. However this is too serious an issue to be left uncommented upon.
Now let me address several key points:
1 UNIVERSAL COVERAGE IS ESSENTIAL: I have been arguing for this for over twenty five years. There are many who get a free ride and many who suffer due to the lack of coverage which results in a small problem becoming a life threatening problem. This time, as compared to the early 1990s with the poorly presented Clinton Plan, there appears to be unanimous approval of a universal coverage. The problem however will be the coverage of those not eligible, such as illegal aliens and non-covered visitors. The latter is easily handled by insisting that anyone coming into the country have evidence of coverage. The latter is a political problem which can be quite costly and still overburden health care.
2 MEDICARE SUBSCRIBERS HAVE MORE THAN PAID FOR THEIR COVERAGE AND SHOULD NOT BE PENALIZED: Perhaps Congress is totally unaware of the fact that Medicare Subscribers have generally contributed more into the Medicare fund in their working lifetime than they will ever get out! Consider a typical individual who works for 40 years and each year has contributed to the Medicare Fund. When that person retires at 65 that person, if they live another 12 years, would contribute to Medicare almost $20,000 as an annuity payment from their 40 prior years of Medicare Payments to the Fund. However Medicare disburses only $12,000 per participant. Clearly there is a gross disparity in how Medicare functions, especially when one considers what one contributes and what one obtains! Statements which allude to Medicare being too generous are fraudulent and frankly are attacks on the aged and defenseless and are below Congress! Medicare has internal problems which need fixing but on a cash in and cash out basis there should be no problem unless there are too many participants who have contributed nothing and thus are burdening those who have.
3 COMPARATIVE CLINICAL EFFECTIVENESS SHOULD BE LEFT IN THE HANDS OF PHYSICIANS AND NOT THE GOVERNMENT: CCE is a normal process of any medical practice. Physicians are always retraining and re-educations. There is a continual input of new procedures, new tests, new methods which any physician must remain familiar with as time progresses. However the concept of CCE as promulgated by the current plans is potentially quite insidious and life threatening. I have typically used two recent examples. (i) Prostate Cancer, recent studies have argued that measuring PSA above 4.0 did not result in any decrease in morbidity. The conclusion is correct but the test was invalid. We now know that 2.0 for men under 65 are best and that velocity of PSA is essential. Colon Cancer: A recent Canadian study stated that colonoscopies were not effective in the transverse and ascending colon. The reason was that there were done by untrained and inexperienced physicians, general practitioners and the like. Endoscopy is a complex specialty. However if the Government were to use these studies in their CCE demands many men and women would die unnecessarily due to deprived procedures. Yet the physician has the countervailing Tort issue to deal with. CCE with Government control is rationing and exposure to litigation.
4 ELECTRONIC MEDICAL RECORDS IS A SUPERB GOAL BUT WILL BE AN EVOLVING PROCESS: The EMR is something which I started working on at Harvard in the mid 1980s. I have developed, tested, and written on this for years. I believe it is essential but the conundrum is that it is a very complex issue. It should be introduced but incrementally. It must be socialized into practices and it must organically evolve from within the profession. I have argued that it should evolve in a manner akin to the Internet with the classic Internet Engineering Task Force, IETF, albeit assisted by the Government and with ARPA participation but a participatory group of those actually involved in implementing it. One knows that any Government approach is doomed to failure and cost explosions!
5 A GOVERNMENT SPONSORED PLAN IS JUST ANOTHER COSTLY CONTROL MECHANISM, INDIVIDUALS SHOULD BE RESPONSIBLE FOR OBTAINING THEIR OWN PLANS AND THEY SHOULD BE TAXED SO THAT THERE IS A LEVEL PLAYING FIELD, Leave The Plans in the Private Sector: This proposal is just expanding Medicare to all people and will result in an even more inefficient system. Equity and Fairness should be the by words. That means that each person should buy their own plan as is done with life and auto insurance. Companies should be taken out f the mix, that is what seems to be the problem and that state of nature is a result of the rice controls during World War II, another form of Government intervention. Keep the Government out, let the market work and make individuals responsible. Subsidies are fine.
6 TORT REFORM WILL REDUCE PROCEDURES AND CUT COSTS: The current system of liability results in increased costs due to both insurance and in terms of defensive medicine. The costs of insurance speak for themselves; the costs of over diagnosing are frankly much more subtle. It is doing an MRI when a clinical diagnosis is more appropriate, it is the cost of prescribing a wider array of medications when patient responsibility would be more effective. The proposals for capping awards, of providing "safe harbors" for procedures and for allowing the use of administrative boards are all productive. No matter what progress here is a sine qua non. It must be part of any new set of laws.
7 BUNDLED PAYMENT SCHEMES ARE BOTH UNWORKABLE AND INSTITUTIONALIZE A BAD SYSTEM: The President and many of the proposed Bills have included the concept of bundling. In my analysis this is totally inappropriate and will lead to a collapse of the system as we know it. It appears to be the creation of some group of academics who have little if any knowledge of how health care works. The unintended consequences of a Bundled approach are many:
1. THE PATIENT AND PROVIDER LOSE A NEXUS: THE RELATIONSHIP BECOMES ONE WITH THE HOSPITAL AND NOT THE PHYSICIAN. IT BREAKS THE FUNDAMENTAL BOND THAT IS THE CORNERSTONE OF HEALTH CARE. The patient and the physician are an important nexus. The only physicians who have little to no contact with a patient are the pathologist, radiologist, and anesthesiologist. The surgeon has contact as does the other specialists. It goes to the heart of practicing medicine. The hospital has the least. In my experience, hospitals are run by managers who care less about patients and more about their bottom line. They are not professionals as are physicians. The only fear a hospital administrator faces is possible loss of accreditation, which only comes after gross negligence if even then. The hospital is run for the benefit of the management and not the patient. By placing the hospital at the focus as is done in a bundled approach one creates a barrier between patient and physician and further places the worst possible party in a position of control, the hospital administrator.
2. IT INSTITUTIONALIZES AND MEMORIALIZES THE HOSPITAL AT A TIME WHEN THE ROLE OF THE HOSPITAL MAY BE AT A MASSIVE TURNING POINT WITH GENETIC MEDICINE. The Bundled approach places the hospital at the center of the model. We have argued that this entity is the most vulnerable to downsizing and change and is also at the heart of the explosion in costs. This is especially true for Medicare patients. Thus we see that placing such an entity at the core creates a tension for continuation of bad practices.
3. IT CREATES MASSIVE PROBLEMS WITH THE ISSUE OF TRANSFER PRICING OF SERVICES AND CREATES THE INCENTIVE FOR FURTHER PADDING BY HOSPITALS. Anyone who has ever been in business, in a large multifunction company, has come to grips with the transfer pricing problem. Many business school doctoral theses have been written on the topic and many a corporate war has been fought over the issue. The price one unit charges another for a good or service is difficult to ascertain. This is difficult even when there is a market for the product. For the buying unit may easily say the internal price is too high and that they will go elsewhere. The hospital could do the same. They may say your physician is too costly so you must accept theirs or no surgery, just go home and die!
4. IT DRIVES GOOD PHYSICIANS OUT OF THE DELIVERY OF MEDICARE SERVICES FURTHER DISENFRANCHISING THOSE ON MEDICARE. Physicians are opting out of Medicare in droves. This means that with the system as it is already, it is becoming harder for Medicare patients to find physicians which will take them. If one adds the burden of bundling then it becomes worse. In our opinion, as we have stated many times in the past, the rearrangement of deck chairs, namely the many plans on how to cut costs via payment and control mechanisms miss the point. First, demand can be modulated, second, costs can be reduced by multiple means, third, genetic medicine will change the paradigm fundamentally and having the agent which will be changed the most in the middle will just delay this change, and finally, and only as the last step is the payment issue.
8 PATIENT RESPONSIBILITY AND MOTIVATION: This is the most critical factor. Take Type 2 Diabetes as a simple example. Its cause is primarily obesity. Its cure, lose the weight. No cost for the cure! It just goes away. However to get a patient to reduce their weight and exercise is a near impossibility. Only 1% is successful. It is worse than smoking cessation and the extent of Type 2 Diabetes disease now costs 12% of the total health care budget growing to 25% by 2020! This MUST be stopped. Akin to smoking I am a true believer in taxing carbs as we tax tobacco. Motivation by education does not work. Motivation by taxation does. Just look at the deaths in men from lung cancer. As taxes have increased the death rate had gone down 50%! This must be done in the carbohydrate area as well.
I hope that some of these ideas will be part of your consideration of the changes in health care. Having spent my time in Washington I am all too familiar with the process. However this will affect us, our children, our grandchildren and generations to come. It is much too critical to be left in the hands of the lobbyists! As I have said to my people time after time, if all else fails listen to the customer! In this case perhaps listening to the voters may be a novel thought as well.
Very truly yours,
June 17, 2009
Dear Senator ,
I am writing your office again to stress several issues which I believe you should consider as the many health care bills seem to be reaching resolution. The following are several points which have arisen as I have spoken with a great many physicians around New Jersey, New York, Massachusetts and New Hampshire. There seems to be a consensus amongst many practicing physicians that they may just become victims of an ever costly and oppressive health care regime run by Washington. I believe that in my conversations there is a great level of demoralization amongst the professionals who feel totally helpless. However this is too serious an issue to be left uncommented upon.
Now let me address several key points:
1 UNIVERSAL COVERAGE IS ESSENTIAL: I have been arguing for this for over twenty five years. There are many who get a free ride and many who suffer due to the lack of coverage which results in a small problem becoming a life threatening problem. This time, as compared to the early 1990s with the poorly presented Clinton Plan, there appears to be unanimous approval of a universal coverage. The problem however will be the coverage of those not eligible, such as illegal aliens and non-covered visitors. The latter is easily handled by insisting that anyone coming into the country have evidence of coverage. The latter is a political problem which can be quite costly and still overburden health care.
2 MEDICARE SUBSCRIBERS HAVE MORE THAN PAID FOR THEIR COVERAGE AND SHOULD NOT BE PENALIZED: Perhaps Congress is totally unaware of the fact that Medicare Subscribers have generally contributed more into the Medicare fund in their working lifetime than they will ever get out! Consider a typical individual who works for 40 years and each year has contributed to the Medicare Fund. When that person retires at 65 that person, if they live another 12 years, would contribute to Medicare almost $20,000 as an annuity payment from their 40 prior years of Medicare Payments to the Fund. However Medicare disburses only $12,000 per participant. Clearly there is a gross disparity in how Medicare functions, especially when one considers what one contributes and what one obtains! Statements which allude to Medicare being too generous are fraudulent and frankly are attacks on the aged and defenseless and are below Congress! Medicare has internal problems which need fixing but on a cash in and cash out basis there should be no problem unless there are too many participants who have contributed nothing and thus are burdening those who have.
3 COMPARATIVE CLINICAL EFFECTIVENESS SHOULD BE LEFT IN THE HANDS OF PHYSICIANS AND NOT THE GOVERNMENT: CCE is a normal process of any medical practice. Physicians are always retraining and re-educations. There is a continual input of new procedures, new tests, new methods which any physician must remain familiar with as time progresses. However the concept of CCE as promulgated by the current plans is potentially quite insidious and life threatening. I have typically used two recent examples. (i) Prostate Cancer, recent studies have argued that measuring PSA above 4.0 did not result in any decrease in morbidity. The conclusion is correct but the test was invalid. We now know that 2.0 for men under 65 are best and that velocity of PSA is essential. Colon Cancer: A recent Canadian study stated that colonoscopies were not effective in the transverse and ascending colon. The reason was that there were done by untrained and inexperienced physicians, general practitioners and the like. Endoscopy is a complex specialty. However if the Government were to use these studies in their CCE demands many men and women would die unnecessarily due to deprived procedures. Yet the physician has the countervailing Tort issue to deal with. CCE with Government control is rationing and exposure to litigation.
4 ELECTRONIC MEDICAL RECORDS IS A SUPERB GOAL BUT WILL BE AN EVOLVING PROCESS: The EMR is something which I started working on at Harvard in the mid 1980s. I have developed, tested, and written on this for years. I believe it is essential but the conundrum is that it is a very complex issue. It should be introduced but incrementally. It must be socialized into practices and it must organically evolve from within the profession. I have argued that it should evolve in a manner akin to the Internet with the classic Internet Engineering Task Force, IETF, albeit assisted by the Government and with ARPA participation but a participatory group of those actually involved in implementing it. One knows that any Government approach is doomed to failure and cost explosions!
5 A GOVERNMENT SPONSORED PLAN IS JUST ANOTHER COSTLY CONTROL MECHANISM, INDIVIDUALS SHOULD BE RESPONSIBLE FOR OBTAINING THEIR OWN PLANS AND THEY SHOULD BE TAXED SO THAT THERE IS A LEVEL PLAYING FIELD, Leave The Plans in the Private Sector: This proposal is just expanding Medicare to all people and will result in an even more inefficient system. Equity and Fairness should be the by words. That means that each person should buy their own plan as is done with life and auto insurance. Companies should be taken out f the mix, that is what seems to be the problem and that state of nature is a result of the rice controls during World War II, another form of Government intervention. Keep the Government out, let the market work and make individuals responsible. Subsidies are fine.
6 TORT REFORM WILL REDUCE PROCEDURES AND CUT COSTS: The current system of liability results in increased costs due to both insurance and in terms of defensive medicine. The costs of insurance speak for themselves; the costs of over diagnosing are frankly much more subtle. It is doing an MRI when a clinical diagnosis is more appropriate, it is the cost of prescribing a wider array of medications when patient responsibility would be more effective. The proposals for capping awards, of providing "safe harbors" for procedures and for allowing the use of administrative boards are all productive. No matter what progress here is a sine qua non. It must be part of any new set of laws.
7 BUNDLED PAYMENT SCHEMES ARE BOTH UNWORKABLE AND INSTITUTIONALIZE A BAD SYSTEM: The President and many of the proposed Bills have included the concept of bundling. In my analysis this is totally inappropriate and will lead to a collapse of the system as we know it. It appears to be the creation of some group of academics who have little if any knowledge of how health care works. The unintended consequences of a Bundled approach are many:
1. THE PATIENT AND PROVIDER LOSE A NEXUS: THE RELATIONSHIP BECOMES ONE WITH THE HOSPITAL AND NOT THE PHYSICIAN. IT BREAKS THE FUNDAMENTAL BOND THAT IS THE CORNERSTONE OF HEALTH CARE. The patient and the physician are an important nexus. The only physicians who have little to no contact with a patient are the pathologist, radiologist, and anesthesiologist. The surgeon has contact as does the other specialists. It goes to the heart of practicing medicine. The hospital has the least. In my experience, hospitals are run by managers who care less about patients and more about their bottom line. They are not professionals as are physicians. The only fear a hospital administrator faces is possible loss of accreditation, which only comes after gross negligence if even then. The hospital is run for the benefit of the management and not the patient. By placing the hospital at the focus as is done in a bundled approach one creates a barrier between patient and physician and further places the worst possible party in a position of control, the hospital administrator.
2. IT INSTITUTIONALIZES AND MEMORIALIZES THE HOSPITAL AT A TIME WHEN THE ROLE OF THE HOSPITAL MAY BE AT A MASSIVE TURNING POINT WITH GENETIC MEDICINE. The Bundled approach places the hospital at the center of the model. We have argued that this entity is the most vulnerable to downsizing and change and is also at the heart of the explosion in costs. This is especially true for Medicare patients. Thus we see that placing such an entity at the core creates a tension for continuation of bad practices.
3. IT CREATES MASSIVE PROBLEMS WITH THE ISSUE OF TRANSFER PRICING OF SERVICES AND CREATES THE INCENTIVE FOR FURTHER PADDING BY HOSPITALS. Anyone who has ever been in business, in a large multifunction company, has come to grips with the transfer pricing problem. Many business school doctoral theses have been written on the topic and many a corporate war has been fought over the issue. The price one unit charges another for a good or service is difficult to ascertain. This is difficult even when there is a market for the product. For the buying unit may easily say the internal price is too high and that they will go elsewhere. The hospital could do the same. They may say your physician is too costly so you must accept theirs or no surgery, just go home and die!
4. IT DRIVES GOOD PHYSICIANS OUT OF THE DELIVERY OF MEDICARE SERVICES FURTHER DISENFRANCHISING THOSE ON MEDICARE. Physicians are opting out of Medicare in droves. This means that with the system as it is already, it is becoming harder for Medicare patients to find physicians which will take them. If one adds the burden of bundling then it becomes worse. In our opinion, as we have stated many times in the past, the rearrangement of deck chairs, namely the many plans on how to cut costs via payment and control mechanisms miss the point. First, demand can be modulated, second, costs can be reduced by multiple means, third, genetic medicine will change the paradigm fundamentally and having the agent which will be changed the most in the middle will just delay this change, and finally, and only as the last step is the payment issue.
8 PATIENT RESPONSIBILITY AND MOTIVATION: This is the most critical factor. Take Type 2 Diabetes as a simple example. Its cause is primarily obesity. Its cure, lose the weight. No cost for the cure! It just goes away. However to get a patient to reduce their weight and exercise is a near impossibility. Only 1% is successful. It is worse than smoking cessation and the extent of Type 2 Diabetes disease now costs 12% of the total health care budget growing to 25% by 2020! This MUST be stopped. Akin to smoking I am a true believer in taxing carbs as we tax tobacco. Motivation by education does not work. Motivation by taxation does. Just look at the deaths in men from lung cancer. As taxes have increased the death rate had gone down 50%! This must be done in the carbohydrate area as well.
I hope that some of these ideas will be part of your consideration of the changes in health care. Having spent my time in Washington I am all too familiar with the process. However this will affect us, our children, our grandchildren and generations to come. It is much too critical to be left in the hands of the lobbyists! As I have said to my people time after time, if all else fails listen to the customer! In this case perhaps listening to the voters may be a novel thought as well.
Very truly yours,
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