nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Friday, July 31, 2009



Update from Massachusetts


From my favorite experiment in universal healthcare coverage, Massachusetts, who recently had to eliminate some legal immigrants from coverage in order to keep going:  support for Commonwealth Care among the population has fallen to 1 in 4.  Note that the MA plan closely resembles the House Ways and Means bill.  See an article here:  While this is just a media article, data is also appearing in peer-reviewed medical journals on how big the problems are.



A Reflection on Longevity and Healthcare Quality. 


I keep hearing the experts claim that people live longer in other countries, therefore they have better healthcare than we do.  This has always bothered me; it’s at odds with my personal experience of healthcare here and what I’ve seen in several other countries.  Why do they all come here, if the results are less good than in their own country?  I’ve never been able to reconcile the feeling that the experts were wrong despite being convinced by the data they use to make the claim….the data seemed clear:  they DO live longer in Sweden, and France, and , etc.


I broke the code yesterday.  I was cruising when I came across a reader’s objection to their analysis of life expectancy. The US has significantly higher rates of fatalities from violent crime and fatalities from automobile accidents.  The “experts” who were making the claim that people in other countries live longer include these statistics, which skew the data to a longer average life expectancy elsewhere.  When you extract the data on violence and car accidents from the totals for all the countries, we have the longest life expectancy in the world. admitted that this objection was true.


When tasked with why they included violent deaths in the total, the experts have replied that, in their opinion, those data ARE a reflection of poor healthcare in our country.  Excuse me?


Look, violent crime and auto accidents are problems…serious ones that need to be addressed.  But, they are not an issue of healthcare access or quality. 


Not everybody agrees. said, after being criticized, that “We’re not sure why accidental death would be deemed irrelevant in a discussion of health care quality, especially in light of claims about emergency care in Canada versus the U.S.  The assumption they are making is that more people die in the US from these things because the care they get--once they get to the hospital--is less good, or delayed.  But, this violates Occam’s Razor:  don’t invent reasons when the simplest answer is staring you in the face.  There are MORE violent deaths because there are MORE violent events.  And, there’s no data that says you are less likely to survive upon reaching the hospital, if injured in the US


For more on this, see


The lesson to be learned here is, you can’t trust anybody’s conclusion from the data…even mine.




Update from the Politicial Process


I noticed that on the same day, President Obama, Speaker Pelosi, and Senator Reid all began blaming skyrocketing healthcare costs on the insurance industry, calling them villains, and morally corrupt, etc.  It’s interesting that the previous strategy that “reform is not going to cost more” is being abandoned (wasn’t working) …along with the tactic of blaming doctors for “doing unnecessary surgery” (like taking out tonsils, as the President claimed).  Senator Reid said that insurance company profits “have increased by 450%.”


So I went to Yahoo! Finance and pulled up data on Net Profit Margin by industry.  Interesting stuff…  Over the last five years, across all industries, the average has been ~5%.  Some industries like Agricultural Chemicals, and Software are doing great, while Auto Manufacturers, Auto Dealers, and Auto Parts are doing poorly…duh. 


But for Health Care Plans it’s 3.2%.  They range from about 1.5 - 4.0%.  And Long Term Care Facilities are losing money at -3.5%.


So we’ll see if the new political strategy works.  I’m against demonizing any particular part of the healthcare industry.  The issues are systemic, not particular, but you hear people yelling at businesses, doctors, drug companies, hospitals, or whatever their favorite culprit is, all the time.



And While We’re Talking About High Drug Prices…


People complain about this all the time.  The evil drug companies and pharmacies are “breaking our backs”, and “why can’t we get drugs cheaper like in Canada?”  And “I know it doesn’t cost the drug company $1.00 a pill to make my medicine.”


You’ll love this:  actually the American consumer is subsidizing the Canadian system.  You should be mad at Canada, not the US drug industry.  How can that be, you ask?  Well…


--About 90% of all the drug research and development in the world occurs here in the US.  Only six countries account for 100% of the new drugs. 

--It costs, on average, $1-2 billion to bring a drug to FDA approval.  The approval process takes 10-15 years. 

--Only about 1 in 300 chemical compounds the drug industry starts to investigate actually end up as an approved medicine.

--Once approved, it’s very cheap to produce the pill…on the order of 10-20 cents apiece (WAG).


OK, a hypothetical.  You’re the CEO of ABC Pharmaceuticals.  You’ve got a product.  How do you recoup the fixed costs ($1-2B) and the production costs (20 cents a pill)?  Simple.  You charge a premium while you still have “biological exclusivity” (nobody else can make it but you), and set the price at $1.00 per pill. 


Here’s the interesting part:  Canada comes along and passes a law that says they will only pay 50 cents a pill for your drug.  You say to yourself:  “OK, I’m getting back my cost to produce the pill, but only part of my investment. Do I sell it to Canada?”  The answer is yes, because you are getting at least some of your investment back:  if you don’t, you get none.


So, how do you solve your business problem?  Again, simple.  You go back to the free market in the US and raise the cost even further, to $1.50 a pill, until you lose rights to the drug, or recoup your costs…then, you drop the price.


When you, the US patient, pay $1.50 a pill for a new drug, 50 cents goes to pay for Canadian patients’ treatment.  Such a sweet deal for Canada, huh?  Other countries do the same, on the backs of Americans.  Maybe we should feel virtuous about this.  We provide a lot of direct aid to developing countries, but we’re also helping developed countries, too.  No wonder their healthcare costs are lower, and ours are higher.


This analysis applies to other medical technology (stents, implants, pacemakers), also.




Physicians contend EARLY Act would do more harm than good.

In an op-ed in the Los Angeles Times (7/31), physicians Steven Woloshin, MD, MS, and Lisa M. Schwartz, MD, both professors of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, write that the proposed Education and Awareness Requires Learning Young (EARLY) Act, now before the House, "seeks 'to increase public awareness regarding the threats posed by breast cancer to young women.'" The physicians call this "well-intentioned and emotionally appealing" bill "a big mistake," arguing that the measure "would end up doing more harm than good" and even "runs counter to" scientific evidence. They point out that the measure "targets women between the ages of 15 and 39," when "fewer than five percent of breast cancers occur before age 40."


Doc D:  I put this in because saying we shouldn’t have a program for a low risk population might be viewed as “rationing healthcare.”  The fact that this bill targets women who are in a relatively low risk group is only part of the problem.  The other part is that in the process of raising awareness we increase worry, for the wrong age group.   The bill also proposes to teach women in the young age group how to avoid breast cancer.   Whether there are any strategies that do this is controversial.


I would rather women and their doctors assess the risk together as a patient-focused action.  Some young women ARE more at risk than others:  if they have a family history of breast cancer at a young age, for instance.  Others are not.  Why paint a broad brush?


Sebelius does not expect adjuvants to be used in vaccine.

On Thursday, the CBS Evening News (7/30, story 4, 2:20, Couric) interviewed HHS Secretary Kathleen Sebelius on H1N1 efforts, asking, "How many adults and children will be tested before the vaccine is available to the general population?" Sebelius said, "I don't know the exact numbers, but there will be testing on adults, testing on children, and testing on pregnant women to make sure that again, we have a safe vaccine. Now, Katie, this is a vaccine that is going to be very similar to seasonal flu vaccine, and we know that millions of children, millions of adults, pregnant women take seasonal flu vaccine year in and year out. The strain is a little bit different, but our scientists have determined that this virus is reacting very much like seasonal flu." She said that adjuvants or additives are "not anticipated" to make it into the vaccine, but "if we somehow have a mutation of the vaccine, it's possible that adjuvants will be used to both boost the reaction...and also to stretch the vaccine further."

        Lancet criticizes US plan to forgo adjuvants. Bloomberg News (7/31, Randall) reports that the US plan not to use adjuvants to "stretch the supply" of swine flu vaccines "would reduce the number of available shots just when other countries need them most, the British journal Lancet said in an editorial." In its editorial, "the Lancet criticized the US for plans to rely exclusively on standard formulations," writing that the "USA must support the use of dose-sparing strategies to avoid depletion of an already short vaccine supply. ... All countries will require the vaccine, but current manufacturing capacity will not be able to meet this demand." HHS spokesman Bill Hall said that the US will "review all clinical data to inform our decision on their potential use" of adjuvants after conducting "human tests to determine safety and effectiveness of flu adjuvants."


Doc D:  I put both news stories in here.  If you develop a product that you hope will produce an immune response in the body that will protect the person from a disease, you hope the product is strong enough by itself to build the protection, but sometimes it’s not enough.  Along come “adjuvants.”  They are additives that boost the immune response to higher levels, or more quickly, or for a longer period of time.  Their use frequently causes controversy.  They can worsen the side effects at the same time they make the vaccine more protective.  Some people say, since we don’t know whether they will do any harm, leave them out.  Others say, put them in if it helps to be more effective.   Blah, blah, blah…


What the Brits are complaining about is the US reluctance to use something that will make the amount of vaccine go farther.  If the US adds no adjuvant there are fewer adverse reactions and a reduced risk of law suits against the government and the vaccine maker.  For those old enough to remember, the Carter administration attempted a nationwide immunization against the flu.  Over 40 million doses were given, but there were several hundred cases of Guillain-Barre syndrome, a paralytic complication, and 32 deaths.  The outcry undermined the program, although it probably saved tens of thousands of lives.  And, guess what?  Guillain-Barre is a rare complication of a number of viral diseases…and of all the flue vaccine you’ve been getting all your life.


So, it’s going to be interesting when we see the press start reporting complications as if they are a result of the new vaccine, rather than a longstanding risk.  I think the government is trying to avoid the political damage that Carter suffered, despite the fact that we may be able to make enough vaccine only for us, but the rest of the world is SOL.  Let’s see if they come up with a principled plan in the end.



Medical quote of the Day:

To preserve one’s health by too strict a regime is in itself a tedious malady.—Maxims, Duc Francois de La Rochefoucauld [1613-1680]


Nature Note:   From Quackwatch:  “The U.S. Court of Federal Claims has upheld the decision of a Special Master that the family of William Yates Hazelhurst had presented no credible evidence that vaccination had caused him to develop regressive autism. The ruling is part of the Autism Omnibus Proceeding in which more than 5,000 families who claim that vaccines caused their children to become autistic are seeking compensation under the National Vaccine Injury Compensation Program (VICP). In February 2009, Special Masters ruled in this case and two others selected to test how similar cases should be handled. The decisions completely debunked the alleged vaccine/autism connection and implied that the doctors who promote (it) are acting unethically.” (emphasis mine)


This is another blow to the “Invisible Evil” crowd that substitutes their own psychological fears for science.  The “Special Masters” initiative is an effort to use experts to rule on a scientific question, instead of judges with little scientific training or knowledge.


Recommended Reading:

--The Joyless Economy:  The Psychology of Human Satisfaction, by Tibor Scitovsky. Originally written in 1976, and rated one of the top 100 books of the 20th Century by the Times Literary Supplement, Scitovsky’s book explored the notion that “there can be little real joy in the lives of people whose every appetite is gratified almost instantaneously,” according to the Foreword by Robert Frank.  Up to that point, economists had assumed that if you get what you desire, you get what satisfies you.  But, these are not the same.  Can what we want be different from what makes us happy?  The answer seems to be “yes.”  Fascinating discussion of the psychology of human happiness.


ERRATA:  I said last week that the House healthcare reform bill requires End of Life counseling (page 425 of the original HR 3200) and appeared to levy a care-terminating provision on one age group.  In looking back at it, it’s not clear that this is a requirement, but also not clear that it isn’t.  The provision references the Social Security Act, where the types of care that are authorized under the plan are defined, and adds this type of counseling to the list of what can be covered.  But when you go back to the House bill, the language is still obscure, listing the counseling, and its frequency of “no more than five years” interval for those over 65.  I can’t figure it out.

When tasked by constituents complaining that they haven’t read the bills they vote on, some members of Congress have said that it does no good to read the bill, because you can’t figure it out anyway.  Maybe this is one of those cases.  But it’s pretty sad when the confusion is allowed to stand.

Sorry for leading you astray.


Doc D

Opinions are entirely my own.  Quotations are from AMA Morning Rounds (© U S News Custom Briefings),, and other sources in the public domain.  As always, you may share this column, with appropriate attribution (here and in the text) included.  Please don’t forward my email address.




Tuesday, July 28, 2009


The analysis of healthcare reform has lurched into action over the last week; analysts are doing a much better job than I can, so I’m not going to concentrate on it.  However, if you’re interested here are a couple of reports:

  1. is an organization that checks the facts that politicians and advocates put out.  They kick everybody in the rear:  McCain, Palin, Obama, DNC, RNC ….  You can survey the website to validate the broad brush they paint.  Here is their analysis of the President’s claims for healthcare and its reform:


  1. The article referenced below discusses some of the statements made in the medical journals over the last few years by the doctors who are key advisors to the President.  One of them is the brother of the White House Chief of Staff, who said the following in Lancet (Jan 31):


“Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years"


So much for the “no rationing” claims.  As a doctor, I find this kinda’ chilling:


Back to some less dismal stuff:


Scientists produce live mice from induced pluripotent stem cells.

NBC Nightly News (7/23, story 8, 2:25, Williams) reported that there is a mouse in China that goes by the name Tiny, and what makes it and "26 others unique is that researchers cloned him -- not from embryonic stem cells, but from another mouse's skin cells."

        Although "some of the mice...had 'abnormalities,'" the AP (7/24, Borenstein) reports, they were able to produce "second and third generations that included hundreds of mice with no noticeable abnormalities." The authors conceded that the "process isn't very efficient; many attempts were needed to get stem cell generated births."


Doc D:  Aren’t there enough rodents in the world already?  But, note that this was done with skin stem cells, not embryonic skin cells.  Another example of how the embryonic stem cell research issue was just a political canard.


Studies challenge conventional wisdom on juvenile obesity trends.

The Wall Street Journal (7/22, Bialik) reports, "Evidence for the expanding epidemic of childhood obesity is thinning. Nutritionists, health advocates, and media reports have been sounding the alarm about a rise in childhood obesity, which could lead to diabetes, heart disease and other problems." Now, new research "from half a dozen countries suggest that rates have held steady over the past five to 10 years, albeit at levels much higher than in the 1960s and 1970s." Still, the reasons for the leveling off in the US, Australia, France, Switzerland, Sweden, and New Zealand "remain shrouded in mystery." The CDC's figures for the US found that "obesity rates among children hovered at about 16 percent between 2002 and 2006," a plateau that came as "a surprise to William Dietz, director of the CDC's division of nutrition, physical activity, and obesity, who notes that prominent anti-obesity-awareness campaigns have only been around for a few years."


Doc D:  While “leveling off” in obesity isn’t what I would call a correction, it may be that a physiological limit is being reached.  Also, obesity could be leveling off because there are only so many times you can do the “arm curl” from your plate to your mouth in a 24 hour period.  Duh…  Benjamin Disraeli said something to the effect that by the time the populace becomes aware of a crisis requiring a response, the problem is already beginning to experience a correction due to natural processes.  I wonder how many millions we will spend to investigate this common sense issue.  Feed your kids sensibly, make sure they exercise, and forget the rest.



Author discusses gut bacteria's potential role in human health.

In a New York Times (7/21) blog, Olivia Judson writes, "The typical human is home to a vast array of microbes," but "only now, with the revolution in biotechnology...we're able to do detailed studies of which microbes are there, which genes they have, and what they're doing." The bacteria in the digestive tract intrigue Judson. "Many of these appear to be true symbionts" that "play crucial roles in digesting food and modulating the immune system." Currently, "a huge effort is...underway to see whether differences in gut bacteria are responsible for differences in health." The gut "microbiome" may contain over "100 times more genes than the human genome," and while "humans are extremely similar to one another at the level of the genome, the microbiome appears to differ markedly from one person to the next."


Doc D:  The industry is already madly putting out expensive macrobiotic supplements and foods, despite a lack of evidence—yet—that they do anything.  It’s almost impossible to do meaningful research on the complex interaction of a “vast number of microbes.”  These products are being sold with no well-conducted studies and under the sobriquet of being “natural”, when most aren’t.  All of these microbes come in your regular food anyway, and there’s no evidence to suggest that getting them separately is any better.  Don’t waste your money—yet.



Study shows experimental AIDS drug decreased virus to undetectable levels in most patients.

Bloomberg News (7/22, Bennett) reports, "GlaxoSmithKline PLC's experimental AIDS drug," called S/GSK1349572, "reduced the virus as much as 500-fold without the signs of resistance linked to treatments from Merck & Co. and Gilead Sciences Inc., a study showed." Data from the first human trial presented at the International AIDS Society's conference in Cape Town, South Africa, showed the drug "decreased the virus to undetectable levels in 70 percent" of the 35 patients in the study. In addition, none of the patients "showed signs of drug resistance," and the researchers "didn't detect genetic mutations associated with resistance to Merck's Isentress [raltegravir] and Gilead's Elvitegravir [GS-9137] either."


Doc D:  We need to watch this one.  If this drug doesn’t promote resistance to other effective drugs, it will really be something.  The problem so far with HIV disease treatment has been having to chase after resistance that develops to every drug we use.



FDA approves seasonal flu vaccine.

USA Today (7/21, Sternberg) reports, "The Food and Drug Administration approved a seasonal flu vaccine on Monday, in plenty of time to protect people against the three standard flu strains expected to spread this fall." However, the FDA warned that "the seasonal vaccine will not guard against a fourth, potentially more dangerous, strain spreading worldwide." The swine flu "has caused more than 40,000 cases and 260 deaths in the USA and its territories." The CDC "recommends flu vaccine for children and young people 6 months to 19 years of age; pregnant women; people 50 and older; people with chronic diseases; people in long-term care facilities; and those who live with, or care for, those most susceptible to flu and its complications.


Doc D:  This is IMPORTANT.  Note that the vaccine doesn’t protect against the new H1N1…but that doesn’t mean you don’t need to take it.  These standard seasonal flu viruses will be around, causing disease.  So, get your shot in the Fall.  The vaccine for the new strain won’t be available until October at the earliest.  Human trials are just beginning:  even if successful, it takes a long time to grow the virus in quantity.  The new illness is turning out to be about as serious as all the others, no more, but viruses can mutate once they get out in the population, so, stand by…


Let me say this again:  TAKE THE REGULAR FLU SHOT AND THE NEW ONE WHEN IT COMES OUT.  (they could be combined, we’ll see..)



Some doctors requiring patients to sign contracts prohibiting online physician reviews.

The Washington Post (7/21, Boodman) reports, "In the past five years more than 40 websites...have begun reviewing physicians, providing information about one of the more difficult and important decisions consumers make routinely." But, "as these sites proliferate -- a reflection of the hunger for information about doctors in an era where patients are expected to make sophisticated decisions about their care -- questions about their usefulness, accuracy, and fairness are intensifying." As a result, some physicians are now "requiring patients to sign broad agreements that prohibit online postings or commentary in any media outlet 'without prior written consent.'" Critics claim these documents are "gag orders," arguing that "they are both unethical and unenforceable." Still, physicians increasingly "view them as an appropriate response to sites that not only ask detailed questions...but also permit comments that may be untrue."


Doc D:  What is good medical care?  For most patients I’ve come in contact with, it’s “getting what you need when you need it.”  That seems to make good sense, but it’s a little vague.  Consider this:  I’m a doctor, you have a tough time getting a quick appointment because I’m very busy, and I am personally somewhat unsympathetic.  My office is clean and hygienic, my staff are professional and courteous, but businesslike.  BUT, my diagnostic process, which you really can’t judge:  why I’m doing the things I’m doing and asking the questions I’m asking—they may seem to make no sense to you—uncovers some elements of your illness, particular to you, that few doctors would have discovered. Therefore, I prescribe a different treatment, which works for you because of your unique findings, despite the fact that it’s not the standard way to do this.  And, finally, you get better faster than you would have otherwise.  Or, maybe you don’t, for reasons that have nothing to do with the treatment…maybe it’s just the illness’s fault (the most common cause of poor outcomes).  Some months back, I recommended a book titled “How Doctors Think.”  It’s a worthwhile read, to get inside the head of someone who’s trying to help you using knowledge you probably don’t have.


Is this quality medical care?  I think so, but I don’t know how it will be reflected on Angie’s List.  Will it be “couldn’t get an appointment” and “nobody seemed to care”?  It depends on personal perceptions of customer service.  When I see a doctor, the things I focus on are the ones I listed above, because it means they are focusing on what I want from healthcare.  I don’t care about the magazines or chairs in the waiting room, and I don’t care…much…about the doctor’s personality—as long as we can get the job done between me, the patient, and him/her, the doctor.  I’m conflicted about this, but if online physician reviews consciously accept that their focus is customer service rather than medical competence, then they’re OK. 



Medical quote of the DayThis is more related to healthcare reform economics, but still a good quote from a Nobel Prize winner. 

“Government is one means through which we can try to compensate for ‘market failure,’ try to use our resources more effectively to produce the amount of clean air, water, and land that we are willing to pay for.  Unfortunately, the very factors that produce market failure also make it difficult for government to achieve a satisfactory solution…. Attempts to use government to correct market failure have often simply substituted government failure for market failure.”  --Milton and Rose Friedman, Free to Choose, 1979.



Fraud Alert:    1.   There’s a fascinating story about how acupuncture got its start in the US back in the 1970’s here:  Like the “Spouse Abuse during Superbowl” phenomenon, it appears that there was a no basis in fact for the claim.  Instead it was assumed that President Nixon’s physician had his appendix operation under acupuncture while traveling in China… in fact he had a standard spinal block.  The author goes on to pursue the sociology of how acupuncture became a fad, which has since been controversial and has often failed in controlled studies to accomplish organic anesthesia.  He tries to make the case that this fascination with an unproven procedure led to the further interest in herbals and supplements that we are experiencing today.  I’m not so sure you can link up the two, but it’s a fun story to read.


Doc D

Opinions are entirely my own.  Quotations and excerpts are from Kaiser Daily Health Policy Report ( © Kaiser Family Foundation), PND News Briefs – Texas Edition ( © 2008, Physician's News Digest, Inc.), AMA Morning Rounds (© U S News Custom Briefings), and other sources in the public domain.  As always, you may share this column, with appropriate attribution (here and in the text) included.  Please do not forward my email address.


Thursday, July 23, 2009


Well, I watched the President’s remarks last night, and they were essentially a cheerleading session.  Don’t get me wrong, he is very good at scripted speaking.  The news conference was what we have seen in the past:  a set of 13 approved questions which the president had prepared answers for.  Again, this is not unusual for some presidents.  He avoided talking about almost all of the specific concerns about the proposed healthcare reform bill, speaking at length in the abstract about what he hopes reform can accomplish.  Two specific things jumped out at me:


  1. He reiterated that people would be able to keep their plans if they are happy with them, but admitted that the government would be involved in managing elements of the plans.  I mentioned that the language we have in the House bill actually forces existing plans to stop taking any new enrollees, prohibits them from making any changes to what they contain, and in five years must conform to the standards set by the Executive Branch for government-approved programs.  That is, they make your plan, that you like, into the government plan.  I read an article here that discusses this more clearly than I do:  If you don’t want an interpretation, you can go back to my reference to page 16 of the bill, HR 3200


  1. He mentioned the statement from the Mayo Clinic that his plan does nothing to control costs or promote value in healthcare, and implied that with reassurances that an independent board of doctors that already exists, called MEDPAC, would be reformed and renamed to IMAC, and given greater power to recommend changes to the plans, the Mayo Clinic was now on board.   That’s a gross exaggeration.  I went to the Mayo website, which I gave you yesterday, and there IS a blog that this would be a “first step” toward incorporating value, but complained that even this small first step will come too late…five years from now.   Also, it’s important to note that the President’s claim that it will be given more power is just a personal assurance, there is nothing in the board’s charter that give it any authority:  they will be appointees of the President, who serve at his leisure, and who make recommendations that he can ignore if he wishes (as those of the former MEDPAC were), and even if he endorses it the Congress can vote it down if they act within 30 days (as before).  I think this is a hollow offer.


No other issues that I or the press have explored were addressed.  The rest was, in the words of one journalist, “The president’s remarks on his chosen subject, health care, were cautious and choreographed, hemmed in on one side by the calculations of his professional wordsmiths, on the other by the delicacy of negotiations with two houses of Congress.   He never detailed his own plan or named a single victim of America’s broken system, and he spoke largely in the abstractions of blue pills, red pills and legislative processes. It’s not easy to turn delivery system reform into a rallying cry for change, but at times, it was as if Obama wasn’t even trying.” (Ben Forbes, Politico 23 Jul)


This will be my last post on this topic.  From last night’s conference, and other interviews with members of Congress on both sides of the aisle, it is clear to me that a lot of work is being done on the published bill to offer carrots to holdouts, twist arms, threaten reprisal, and all this is being done invisibly.


I predict that there will be a massive re-working of the bill which will be released late one afternoon, and then a large amendment will be slipped under Congressmembers’ doors during the night, and then a forced voted on passage the next afternoon, before anybody has a chance to know what’s in it.  This worked for Cap-and-Trade…and precludes close scrutiny that would make moot further declining support for the proposed reforms.  The danger is that this becomes a Democrat plan imposed on the nation, there’s rising outrage over pushing legislation that nobody has even had time to decide whether they want to vote for it or not, and the administration risks backlash.  Maybe they think that the payoff is worth the price, since they are steadily approaching reduced effectiveness anyway.


Any bets on whether I’m right?


Comin’ atcha with the regular format for this newsletter until something striking happens.



Doc D


Opinions are entirely my own.  As always, you may share this column, with appropriate attribution (here and in the text) included.  Please do not forward my email address…thanks.

Wednesday, July 22, 2009


Here are a few hypotheticals about healthcare reform:


  1. You are a single adult male.  Should your healthcare premium be the same as that of a couple, or a single female, who are planning a family and need obstetrical care?  That is, should your premium be increased to cover obstetrics?


--This question is an extreme form of the level-playing-field argument in insurance risk analysis, and involves gender equity.  It’s understood that if this male got married, the couple would need to share premiums with others who may need obstetrics.  But what about other risks:  smoking, obesity, heart disease, or history of heart disease.  At bottom these questions test your philosophical outlook on “what we owe to others.”


The current bill:  Congressional testimony on this point was offered that the single male would have to pay extra for obstetrical healthcare he would never require if he remains single.  To not do so would unfairly punish women; to do so levies a fine for being male.  There are arguments either way…although as usual most will justify their pre-existing belief on the point rather than be swayed by argument.


  1. You don’t think you need healthcare insurance, so you wait until just before the end of the calendar year to enroll.  Therefore, when you file a federal tax return with the IRS, you are not charged the tax for not having coverage (the amount varies depending on your income—for most people it will be several thousand dollars).  Immediately after your return is filed, you cancel the policy.


--The individual dodges premium payments for most of the year, thus not paying their fair share.


The current bill:  Nothing in the draft bill disallows this.


  1. You decline to enroll, but find that you need an expensive elective surgical procedure (like having your gall bladder taken out).  You enroll, payment the initial premium, get your sugery done, and once you are well and all costs have been paid by the insurer, you cancel the policy.


--As above, this allow the individual to pay a few hundred dollars to the insurance pool, and get a $20,000-50,000 operation done, the balance being paid by increased premiums for those people who are covered year-round.


The current bill:  Nothing in this draft makes this impossible (I’m about 90% sure on this one; I couldn’t find any lawyer-ese in the bill on it…so…grain of salt).  This IS being done in Massachusetts according to recent articles, and is contributing to the huge cost overruns of their universal care plan.



It takes time for these issues to be discussed and addressed.  None of that has occurred yet.



Doc D


Opinions are entirely my own.  As always, you may share this column, with appropriate attribution (here and in the text) included.  Please do not forward my email address…thanks.


The national discussion on Healthcare Reform is beginning to smolder as the supporters and detractors begin to sort through the details of the plans.  I’ve read through the rest of the bill quickly since my last newsletter.  Forgive me if I pat myself on the back for prescience.  Some issues I identified to you have reached the media:

1.  Recall that on page 16 of HR 3200 ( ), the America's Affordable Health Choices Act of 2009, there is the convoluted “no choice” language that appears to controvert the President’s oft-repeated promise that people who are happy with their plan can keep it.

The president was asked about this part of the bill in one of his press conferences, and he replied “I’m not familiar with that provision of the bill.”  This doesn’t sit well, since his promise was a major selling point for that 70-80% of Americans who are happy or very happy with their current plan.  It undermines his sincerity in pursuing rapid passage, without the time for an informal referendum by ordinary Americans.  If he doesn’t know about this item, what else does he not know about the overall plan?  It suggests that his goal is political rather than reformative (if that’s a word).

  1. Also recall that on page 425 I said that there are provisions which require seniors to have their personal health plan and status reviewed every five years, in accordance with a government checklist that’s in the language of the bill.

The implications of this are becoming a concern among seniors and their organizations:  why do they have special scrutiny?  Aren’t health prognostication, advice, and planning for the future a topic for all Americans?  The concern is that this provision concentrates on government-driven standards for when people should consider termination of care, focused on only one group.

The political cost of potentially allowing taxpayer funding for abortion, is another dumb mistake.  As you know, I consider this issue to be complex.  BUT, now slightly over 50% of the country does not support the procedure:  why put that in the bill and undermine support further?

PS:  I found the following in the second half of the bill (this could be incomplete, it’s mind-numbing to read):  two new agencies, three new committees, several Task Forces, a Medical Device registry, and research money for a lot of pilot programs.  By the way, on these pilot programs, in almost 30 years of government service I am unable to recall an instance where government has been innovative.  Only industry does this.  In every case where a successful program has been adopted, the idea came from free enterprise.  If you can think of an exception, I’ll be happy to look into it.

PPS:  members of Congress are exempted from having to enroll in the new plans.  It would be a nice gesture of their belief in reform, but they have the Federal Employee Plans choice, and are not eligible to change. So, fat chance they will amend this.

I’ve just scratched the surface of those things that jump out at me, but as we get deeper into the bills, a lot of screwy things are coming up that make it the height of lunacy to rush to passage.  This shouldn’t be about the administration’s future.  Or, as the White House Chief of Staff was reported to have said months ago, “No crisis should be wasted.”  Meaning that politically it’s smart to press forward quickly in the Honeymoon period of the presidency, using that political capital and the people’s fears, to accomplish as much as they can.  Don’t mistake me, this is smart politics, it’s just focused on the party’s interests, which may or may not be in the nation’s interests.

From the medical profession side, it is useful to know a few things.  For instance, the AMA issued a formal statement supporting the above plan.  Firstly, while the AMA is the largest advocacy and professional group for physicians, the last time I checked, less than 1 in 4 doctors belong to it.  It’s largely seen as not relevant to the practice of medicine (I disagree), and most doctors just want to see patients and stay out of anything else.

Secondly, the AMA sold out to the administration for ~$238B in increased payments for Medicare and Medicaid.  For many years, those payments have been kept low, and each year are supposed to be cut further.  Every year Congress has to pass a bill to keep the cuts from going into affect.  Reimbursement for Medicare/Medicaid are in the 80% range of those payments of other plans, so many doctors don’t prefer these patients, and accept them only when necessary, or when a patient of theirs turns 65 and transitions to Medicare.  The president promised to payback the $238B “doctor fix” and to adopt a different formula for reimbursement in the future.  So the AMA sold out for money.  For me there are other troubling provisions in the AMA’s agreement with the Prez:  they agreed to using “outcome measurement at the point of care.”  This means that doctors will get guidance from government agencies on what they do in the examining room as to what tests, drugs and treatments they can use for all patients with a certain medical problem.  The AMA’s statement on their support is at if you would like to dig into it.

Also of note, is that the administration does not include this $238B in their analysis of the cost of reform, they don’t consider this payoff a cost.  Which is why you will see administration officials arguing that the $1 trillion bill is not correct.  You can always make the total sound better when you exclude certain things.  As always, in politics the side that controls the definitions, wins.

By contrast, while the President has been using the Mayo Clinic as his example of high-quality, cost-controlling healthcare in numerous speeches on the campaign trail, and during his term, that compliment has been spurned.  The Mayo Clinic, which, as the President himself says, is an internationally acclaimed center of excellence in healthcare, has issued a statement that

the proposed legislation misses the opportunity to help create higher-quality, more affordable health care for patients. In fact, it will do the opposite.

In general, the proposals under discussion are not patient focused or results oriented. Lawmakers have failed to use a fundamental lever – a change in Medicare payment policy – to help drive necessary improvements in American health care. Unless legislators create payment systems that pay for good patient results at reasonable costs, the promise of transformation in American health care will wither. The real losers will be the citizens of the United States.”

This is a big blow.  The question of cost v rationing has become the conundrum, with the independent Congressional Budget Office testifying that the House plan does nothing to reduce cost, and will increase the deficit by $1.3 trillion over the next 10 years…and still not cover all the people who are uninsured.

Just this morning the President invited the CBO director to come to the White House to “discuss” their analysis.  I’m sure the focus was to get them to reconsider how they are calculating the total.  Meanwhile, the DNC and the RNC are pushing ads in possible swing states, and the President will address the nation tonight to urge support.  It’s just my opinion, but he’s spending the value of the Bully Pulpit very quickly.  I read a report that the media is starting to back off of coverage of some of his appearances because there is little new information and he’s appearing so often that it’s becoming a footnote.   It may be that he’s willing to break the bank on his popularity in order to get stuff done very quickly.  All of the polls are creeping down, and in the opinion of one commentator, “once a President’s approval reaches the 40’s, he becomes a caretaker.”  Maybe not, these things can change.

Speaker Pelosi, has said that the proposed plan has “a cap of costs, not on benefits.”  I hope you realize by now that these are not independent variables, and I can see virtually nothing in the bill about costs, only benefits.

I recommend that you watch the President’s briefing:  will it be another cheerleading session, or will he address the substantive issues, at least one of which he is “not familiar with”?

One thing I haven’t discussed is the potential for alternative plans.  There are a ton of them out there.  Consider the following:  The Center for Medicare and Medicaid Services (CMS) estimate that 70-80 billion dollars are wasted annually due to Fraud, Waste, and Abuse (FWA).  Multiply this figure alone by 10 years, and you get the funding that would pay for most of the $1 trillion cost.  However, in the current Democrat plans there is no, to minimal, provision to address this.  Why not?  Several other Democrat and Republican alternative plans address this directly.

A clarification is useful about FWA, some people think it refers to criminal doctors.  There are some of these, but the underlying problem is that CMS has no resources to pursue more than a small fraction of these abuses.  And as long as they can’t, the bad actors will continue with relative impunity.  However, a substantial part of FWA is that the people who process the Medicare and Medicaid claims are GS 3-4 workers.  This is the lowest paying personnel rating in the federal personnel system.  As a hospital commander I found that my employees who were responsible for “coding” what was done in the hospital were wrong 15% of the time.   The code is what establishes what the patient’s diagnosis is, and is the foundation for how the government (and industry) decides how much to reimburse.  Once I gave them more training, lobbied for GS 7-8 supervisors, and got the docs involved, our accuracy improved dramatically.  When Medicare errs in processing, this is also Waste.  I haven’t seen figures for what percentage of the $70-80B comes from this category.

To bring this long discussion to an end, I want to repeat something I said a while back.  The numbers of the uninsured are variously quoted in the media, and it creeps up through a form of “data inflation” that everybody is guilty of.  Me too, although I try to smack myself around when it happens.  That’s one reason I give you the references, so you can check them out and decide for yourself.

Take 47 million people as the most recent figure.  Here’s how that breaks down:

Original total                                                                                                                                                     47M

            Adults and children who qualify for Medicare/Medicaid/CHIP who haven’t enrolled                                    9                      -I can’t find out why they don’t.  The fix is just to get them enrolled.

            The wealthy that don’t need insurance                                                                                                     2                      -If you make a lot is makes more sense to just pay out of pocket, rather than pay premiums for coverage you may not use.

            Those adults who are between jobs at the moment and will be covered again within a few months             14                     -The fix here is portability of insurance between jobs

            Illegal immigrants                                                                                                                                  8                      -You can argue whether we “should” enroll them—either as a moral issue, or that they will just go to ER’s.

            Adults aged 18-30 who can afford coverage but decline to do so                                                            2                      -they’re healthy, have other priorities, and don’t see the need.  Under the bill above, they HAVE to pay.

Remaining uninsured                                                                                                                                         12M                  -note that there is rounding error here.

There’s another wrinkle:  there are people who have a military or federal employee spouse, who may want to use only their spouse’s plan, and not enroll in an employer’s plan.  I just can’t tell how much this skews the above.  It’s a personal decision.  The bill is clear that employers will have to pay the ~8% tax for each employee who doesn’t enroll (even if the employee decides to enroll elsewhere—now that’s weird), but it’s not clear about the military and government workers spouses.

Twelve million is less than 5% of the population.  My summary is primarily taken from the Kaiser Foundation’s studies.  For those of you who are unfamiliar with them, they are a highly respected, non-partisan research organization who support universal coverage, but publish accurate data.  In my opinion this is our real target for reform.

Again, he who controls the definitions, wins.

Everyone, including both parties, agree that we need healthcare reform.  If we don’t pay attention to “what kind” of reform, we will get the change, good and bad, that we deserve.

Doc D

Opinions are entirely my own.


What I'm Reading - Updated 3 May