America’s HealthCare Crisis: Part IV.  Physician, heal thy profession.

One bright sunny day two decades ago, I stood rather nervously in an examination room, taking an oral examination in order to graduate from medical school.  The examiner stood a few feet from me and with a curtly nod summoned a patient.  The patient shuffled in and the examiner observed his watch.  After thirty seconds, he nodded again, and the patient shuffled out.  The examiner turned towards me.  “Your diagnosis, doctor?”

That was a different era, an era where physicians were scientists, trained observers and good listeners.  It was an era when physicians spent time with patients.  How times have changed.

In thirty seconds, I observed that the patient’s right shoulder drooped, he took shallow quick breaths, and that he was rather emaciated.  Pulmonary insufficiency afflicting the right lung, secondary to either tuberculosis or cancer was my diagnosis and I passed.  I was able to make that diagnosis because I had been taught the importance of taking a good history and performing a thorough physical examination.  By the time of graduation, those skills had been mastered.  Though the two can be time consuming, they are a lot more cost effective than modern tests.  But more importantly, they establish a rapport between physician and patient that is priceless. 

These days, physicians spend less than 5 minutes with a patient and move on after ordering myriad laboratory or radiology tests.  The art of a differential diagnosis that required options to be carefully vetted has been lost to batteries of expensive tests.  How many patients can attest to their physicians having spent time with them, and lent a sympathetic ear?  Sadly, centuries old sacrosanct trust that existed between patients and physicians has been relegated to history books.  A physician is not looked upon as a knowledgeable family friend but as a glorified laboratory technician out to make a bundle. 

The mentality of conducting tests rather than dealing with patients directly contributes to the health care crisis.  In my last op-ed, I had mentioned that it took a CAT scan to identify my neighbor’s neck mass, something that any physician worth his/her salt should have identified from across the room.  If such tests are to replace the eye, is it any wonder that medical expenses have sky rocketed?  A gastroenterologist I know brags that he does not even touch a patient any more.  He sends them straight for radiological imaging or endoscopy.  Since he spends less time per patient, he can see many more patients a day, enhancing his income considerably.  Unfortunately patients fall for this, assuming that more and expensive tests are better.  While directed tests to prove a diagnosis are very understandable, testing simply to replace the process of physical diagnosis process is very wasteful.

Physicians argue that the legal atmosphere or patient pressure forces them to perform myriad tests.  While both arguments are true to some degree, physicians must ask themselves who ultimately dictates standard of care.  Lawyers do not establish standard of care – physicians do. 

A big issue for practicing physicians is insurance coverage.  Filling out paperwork, arguing or petitioning insurance companies can eat up 40 – 50% of the practice income in administrative costs.  In fact, Medicare and Medicaid are cause so much angst that some physicians do not take it at all.  They either ask patients to pay cash, or see them for free.  This is indeed a laudable trend and if all physicians were to follow this practice, insurance companies would have their wings clipped.  Since physicians cannot form unions (so much for following the constitution of the US), this would have to be a spontaneous mass movement.  In contrast to the Obama administration and Congresses penchant for a government run insurance or ‘heath exchange’, which I think will create just more government jobs but not much else, the profession may be better off with less insurance mandates, not more.

Another aspect of medical care is related to therapy – after all, the increase in life expectancy over the past five decades is due largely to life saving drugs developed by the pharmaceutical industry.  However, despite our appreciation for the pharmaceutical / biotechnology companies and their products, we should also keep in mind that they are in part responsible for the increase in health care costs.  In this area, physicians can do a lot to curtail runaway prices.  An example would be prescribing generic drugs instead of brand name ones.  It is wrongly assumed that generic drugs are somehow inferior to brand name drugs, at least when it comes to chemical entities (the situation with biologics is more complex).  Generics have to prove their safety and equivalence to branded drugs before the FDA approves them and there is no reason to prescribe expensive brand names while cheaper alternatives are available.

My last comment is to exhort physicians to take back the practice of medicine.  To take it back to an era where physicians were respected and the profession was an honored one.  To take it back from bureaucrats, lawyers, and insurance company executives whose short term vision is dangerous to patients and the field of medicine.  In short, physician, heal thy profession.

America’s HealthCare Crisis.  Part III: To sue or not to sue, that is the question.

''The first thing we do, let's kill all the lawyers.'' (Shakespeare in Henry VI, part 2, Act IV, Scene II).  A follower Jack Cade, who seeks to overthrow the government, utters that refrain.  Shakespeare's acknowledgment that the first thing any potential tyrant must do to eliminate freedom is to "kill all the lawyers" illustrates the central role lawyers have played in modern civilization, irrespective of weather that role is positive or negative. 

On the positive side, the legal profession has codified laws and drafted constitutions of many countries, giving recourse to the weak and oppressed against the powerful and privileged.  The profession has played a critical role from civil rights (as exemplified in Rosa Parks Vs Alabama) to education (for example Clarence Darrow who defended Scopes for teaching evolution in Tennessee).  Even in healthcare lawyers have done the society a favor by siding with physicians against big tobacco.

On the negative side, the mercenary behavior of some lawyers has left the reputation of the field in tatters, with lawyers now occupying a status in society only a notch above bankers, stock market analysts and politicians (at least for the time being).  Few would claim that F. Lee Bailey or Johnny Cochran had anything more sublime than dollars in mind when they took up the cudgels on behalf of OJ Simpson.  Armed with the knowledge of laws that they often drafted, the can tie up businesses and individuals in a vicious legal entangles that lead to the destruction of businesses and persons.  It is therefore not surprising that a study described in Investors Business Daily concluded that lawyers constitute the only section of society that actually decreases the gross domestic product of a country. 

Lawyers on the whole have done the most damage to the medical profession and ultimately to the supposed beneficiaries, the patients.  The litigation threat has affected trust between physician and patient.  Medical care should be driven by patient-physician respect, not by actions of lawyers.  How can this rapport be established if the physician wonders about every patient being a walking lawsuit? 

Dragging a physician to court for every perceived mistake, however small or understandable, has led to defensive medicine wherein all kinds of tests are ordered to avoid the remotest possibility of overlooking something.  A physician should not have to conduct tests s/he does not think necessary but has to simply because it could be used against her or him in court. 

A physician undertakes therapeutic interventions that s/he considers best for the patient.  However, every medication or procedure has side effects or interactions that can be unforeseen and serious.  A physician should explain the most likely and the rare but serious possible adverse outcomes.  But it is impossible to list every single reaction for every single intervention and the physician cannot be held accountable.

It cannot be denied that medical mistakes are made, some egregious, for which the victim or patient should be compensated.  However, there is no reason why that compensation should drive the average physician out of business by virtue of raising insurance premiums to ridiculous levels. 

Tort reform has already been proposed to correct this anomalous situation, placing limits on payment for “pain and suffering”.  However, to redress the balance, here are some other remedies that could be applied

1.                  Lawyers should be liable for cases they loose by paying court cost and time spent by the defending physician.  This should decrease frivolous lawsuits.

2.                  Lawyers should not be paid a contingency of 30% - 50%, as is the case now.  That amount should be reduced to not more than 10% of final settlement as has been proposed in Florida.  Financial incentive should not be a driving force here, genuine concern for the litigant should.

3.                  Lawyers who file more than a pre-specified number/percentage of frivolous lawsuits should be barred, just as doctors who commit medical fraud should be de-licensed.

4.                  Juries should be comprised of peers of physicians, nurses, and physical therapists, and physician’s assistants, under the supervision of judges so that the medical profession does not police itself.  Juries should not comprise of those not intimately familiar with medical profession since they do not have the required knowledge to judge the appropriateness of medical care.

Maybe when all the above changes are made, medical care will switch back to caring doctors and not sue-happy lawyers.

America’s HealthCare Crisis Part II: How much is that policy in the window?

Warren Buffet likes insurance companies.  Take a look at his portfolio and you will find several insurance companies in it, including re-insurance companies (companies that insure other insurance companies).  That is because insurance companies have a great business model (despite the licking they have taken over the past year and half).  They can, and do, select their customers carefully, picking out those most likely to make them money.  They raise their prices as and when they want to.  And they are notoriously bad at paying out claims.  So though they may be great for Buffet’s portfolio, they can have a profound impact on businesses they deal with.

Take their influence on the medical profession.  A doctor has no choice – the legal community has made sure that a non-insured doctor is an extinct species.  And as the doctor goes shopping for medical malpractice insurance, s/he is at the mercy of insurance companies who jack up the fees to make sure that the doctor pays for hypothetical lawsuits that may or may not occur.  An obstetrician can pay as much as half her/his income on getting medical malpractice insurance.  No wonder some specialties are dying, and in some states there is an acute shortage of obstetricians. 

The insurance companies have an equally important influence on patients.  In combination with health management organizations, they dictate medical care.  The length of a visit is pre-determined – based on the estimate of some bean counter who determines profitability, not medical complexity or appropriateness.  It is no wonder that patients do not feel that doctors do not them give adequate attention.  Insurance companies also determine what procedures get done, again based on profitability concerns.  If a patient gets frustrated with his/her insurance, they can always switch.  At least in theory.  There is a bewildering array of false choices, with all kinds of restrictions on doctors (in network or not, primary care or specialist, etc), medications (co-pay, generic or trade name), pre-existing conditions, etc.

It is therefore not surprising that the “health care reform” efforts in the Congress and by the Obama administration targets insurance companies.  Understanding the concerns of a government run insurance company various alternatives have been mooted, such as a ‘non-profit exchange’.  Naturally, the insurance companies are against it.  After all, how could they compete against a government-run non-profit?  The insurance companies cite patient satisfaction data that show that a majority of patients are satisfied with their insurance.  What is left out in the survey is the fact that most such patients have company sponsored insurance plans, an anachronism of the 1940s and 50s.  Ask the same question to those who pay for their own plans, and we may very well see a different response.

It is clear that any health care reform will have to address the issue of insurance companies.  But what form of  should it take highly debatable.  Should there be a single payer system, doing away with insurance companies all together?  Should business paid medical insurance be taxed?  What about Medicare and Medicaid, the two big elephants in the room that will probably be bankrupt soon?  Should they even exist if there is to be an insurance ‘exchange’?  There are several alternatives, among them

1. I agree with some in the Congress, and also with Senator McCain, who suggest that business provided insurance should be taxed.  In fact, businesses should get out of providing any health coverage.  That is the responsibility of the patient, not the company.  While a company can provide incentives for healthy behavior, such as not smoking or belonging to a gym, providing health care insurance promotes over-use by those receiving it.  It also ties employees down to jobs that they dislike, but stick to due to health insurance.  Thus, I obviously oppose the Obama administrations proposal or mandate that businesses should be required to provide health care.
2. Do we need yet another government run organization?  In fact, maybe it is time to get rid of Medicare and Medicaid.  The latter is about to go bankrupt, and fewer and fewer doctors accept it.  The former is not too far behind and if they are not discontinued voluntarily, they will either bankrupt the US or will go down in flames on their own.  Which leads me to point 3.
3. If the government is truly concerned about the un-insured or those who cannot afford it, bite the bullet and make the US and two tiered health care system.  Have government run clinics and hospitals where every one can get some degree of free care.  Let the private sector be unregulated, so those can afford to and want private healthcare can do so without any government restrictions.  The obvious criticism of this proposal is that the government run system will provide second rate care.  I agree that it will, but attest that that second rate care is better, and cheaper, than being uninsured in the present system and having common ailments taken care of in the emergency room.
4. For medical malpractice insurance, I think it is time to reform tort laws, which is the subject of the following, third article.

America’s Health Care Crisis: Part 1.  Whose responsibility is it anyway?           

As “Health Care Reform” careens down an unknown path in the Congress, let us spend a few moments to analyze how we got into this mess.  Americans spend $2.4 trillion a year on health care. The Business Roundtable reported that in 2006, Americans spent $1,928 per capita on health care, at least two-and-a-half times more per person than any other advanced country.

In a different twist, the report took those costs and factored benefits into the equation. It compared statistics on life expectancy, death rates and even cholesterol readings. The health measures were factored together with costs into a 100-point "value" scale.

The United States is 23 points behind five leading economic competitors: Canada, Japan, Germany, the United Kingdom and France. The five nations cover all their citizens, and though their systems differ, in each country the government plays a much larger role than in the U.S.  The cost-benefit disparity is even wider -- 46 points -- when the U.S. is compared with emerging competitors: China, Brazil and India.

So, how did we get here?  There is plenty of blame to go around, including lawyers, insurance companies, doctors and we, the people.  This series will assess the role of each segment.  First, let us look at our role as consumers and see how our behavior has contributed to this mess.

A few months ago, one of my neighbors (lets call him Q) was driving to New Jersey on I-78 when he began to feel unwell.  He felt weak and nauseas, and had a headache.  Q managed to work half the day, but then his condition deteriorated.  After calling his wife, he drove home, without informing his physician about his condition.  The wife waited at home, wondering whom she would hear from first – her husband, the emergency medical services, or the highway patrol.  He did end up reaching home safely, without causing a wreck or injuring other drivers on the highway, but they ended up going to the emergency room that night.

The story gets more fascinating at this point.  After many tests in the ER, Q was hospitalized.  He had a history or high blood pressure and was about 100 pounds overweight.  Disregarding his doctor’s advice to loose weight and exercise, he had carried on, concluding that he was too young to worry about strokes or heart attacks.  After all, he was only in mid-thirties.  But Q wasn’t too young, and he ended up with a stroke.  Fortunately for him, there was no permanent neurological damage.  Unfortunately for him, the tests revealed another problem – he had a mass in his neck that was detected by computerized axial tomography (commonly known as the CAT scan).  That it required a CAT scan to identify a mass that should have been detected by a physical exam is a point that will be addressed in a subsequent column, but to cut a long story short, he was suspected of suffering from a lymphoma.  Many tests followed, most of them unnecessary, with attendant expenses and anxiety, till he was proven to be cancer free.  And then, Q lost his job.  While the company laid-off others as well, undoubtedly his case was complicated by medical bills.  A few months after this, I asked Q what medications he was on, and he looked at me with a vacant expression and said, “I don’t know.”  He now has trouble finding a new job that is commensurate with his experience and training.  Part of the reason is the health care premium his new employer would have to pay.

This story reveals several aspects of what is wrong with the health care system, such as the attitude of patients, doctors, lawyers, and insurance companies.  This column addresses the behavior of patients.  We in America have gotten used to being taken care of by someone else and over a period of time, have lost the sense of responsibility. Health has become the responsibility of everyone but the patient.  However, shouldn’t health the patient’s own responsibility?  Why should the government or a doctor be responsible?  A doctor IS responsible for providing guidance and counsel.  However, the ultimate responsibility is that of the individual.  And if that individual chooses to live on a diet of hamburgers, fries, and considers watching sports on TV the best way to exercise, is it a surprise that obesity, diabetes, hypertension, and heart disease ensue?  While suing may enrich a lawyer and provide a sense of satisfaction in retribution, it won’t solve the problem. 

Avoiding disease should be the first health care priority and responsibility of an individual.  That includes proper diet, exercise, vaccinations, and common sense actions such as wearing helmets, seat-belts, avoiding unprotected sex, etc.  However genetics, age, and environmental influences affect even the appropriately behaved persons, and that is where the second priority comes in. 

The second health care responsibility is to understand and educate oneself to disease(s) that afflict a person and also to familiarize oneself to the therapeutic modalities.  If an individual has hypertension, s/he needs to know the therapies available.  Unlike Q, who did not his medications, a responsible individual should not only know the names and doses of the medications but also the side effects and interactions with other medications.  In the Internet era, knowledge is not hard to come by and lack of access is no longer an excuse. 

The third health care responsibility is to follow instructions meticulously.  If exercise is advised, it should be followed.  If an antibiotic is prescribed, it should be taken as prescribed, and not stopped half way through. 

By taking responsibility for our own health, we can save the health care system from a catastrophic breakdown.

As of this morning, November 29, 2008, more than 180 people have been killed in attacks in Mumbai.  At least four Americans are among the dead. What motivated the attackers, other than hate and a fundamental disregard for civilized behaviour? Kashmir. Yet, most American’s have no idea what Kashmir is. But they should, since it is one of the basic reasons why we are stuck in Afghanistan (to paraphrase John Kerry), and why Islamic terrorism came to America’s shores. Kashmir is the reason why Pakistan does not cooperate adequately with the US in the war on fundamentalist Islam whether that be the Taliban, Al-Queda, or what ever other form it takes.

Kashmir is a part, and I repeat a part, of the state of Jammu and Kashmir (J&K), over which India and Pakistan have gone to war at least two times. Kashmir is not a homogenous state, but is actually composed of three very different regions. There is the Muslim valley of Kashmir, the desert plateau of Buddhist Ladakh, and the mountains of Hindu Jammu. History is important here, so allow me to expand on this.

When the British, in their infinite wisdom, decided in 1947 to partition Colonial India into India and Pakistan along religious lines, the idea was that Hindu areas would go to India, and Muslim areas would go to Pakistan. So far so good, with the exception that more than 1 million died in the process, but we won’t let that little bit of detail get in the way of the great legacy of the British Empire. But we do have to deal with the two other exceptions – the states of Hyderabad and J&K.

Hyderabad had a Muslim ruler and a Hindu population. The Muslim ruler, the Nizam, decided to join Pakistan, but India’s savior, Home Minister Sardar Patel, decided otherwise. He sent Indian troops, much against the wishes of the wishy-washy Fabian Socialist Prime Minister, Nehru, and secured Hyderabad (now Andhra Pradesh) for India.

The problem with J&K was the reverse. It had a Hindu king (pardon me, Maharaja) and a Muslim population. The people wanted to join Pakistan (or so Pakistan claimed), but the Maharaja was unsure. Impatient, Pakistan sent tribal fighters into J&K to force the Maharaja. It had the opposite effect, and the Maharaja appealed to India for help. That help came after he signed away his kingdom. Once the treaty of accession was signed, Indian troops moved in and kicked out the tribals from most, but not all, of Kashmir. Notice – Nehru did not object to this. Why? His forefathers were from Kashmir and emotions take precedence over correctness. A temporary peace treaty was signed between the two newly independent countries. A line of control (LOC) was established where Pakistan controlled part of J&K (also called Azad Kashmir) and India the rest (still called J&K).

The Pakistanis cried foul. They claimed that India was having the cake and eating it too by holding onto both Hyderabad and J&K. The issue was taken to the UN by a naive and foolish Nehru, where a resolution was passed to hold a free and fair referendum about Kashmir’s future. More than 50 years later that referendum has not been held. Indians claim that a referendum cannot be held so long as Pakistan holds on to parts of J&K. Pakistan won’t give Azad Kashmir back to India hoping that the referendum will be held.

So, India and Pakistan have gone to war two times over J&K (and a third time over Bangladesh). This enmity has been a boon to carnivores and arms merchants, who have played India and Pakistan against each other for their own material gain. But now the stakes are higher. The fourth war between the two countries will be a nuclear one.

That does not seem to bother Pakistan. Having lost the war in 1971 to India, resulting in half the country (then known as East Pakistan) being torn apart as a new country (Bangladesh), it has become desperate, obsessed and vengeful. After 1971, knowing it could not defeat India militarily it began to craft a new strategy – terrorism. And the idiotic Soviet Union played right into this by invading Afghanistan. Pakistan’s dictator, Zia Ul Haq, took advantage of this by aligning himself with Ronald Reagan’s determination to defeat the Evil Empire by helping creating the Islamic Mujahideen.

Ronald Reagan was fixated on USSR and did not understand that he his cure, in the form of carte blanche and billions of dollars to the Islamic Mujahideen, was worse than the disease. The long-term implication of this misguided policy was that Islamic fundamentalists, supported by Pakistan, came to power in Afghanistan. America, and the world, walked away. Pakistan did not. It’s spooks the ISI (Inter Services Intelligence) soon created another even more fundamentalist group, the Taliban that ultimately won over the country. That gave the Pakistanis “strategic depth” and the ability to bleed India dry by sponsoring terrorism. The Jihadis that trained in Azad Kashmir to undertake ‘war by other means’ and the Taliban were born, bread, and nurtured by the same organization and source – the ISI. Their cross-fertilization was perhaps best illustrated by the hijacking of the Indian Airlines plane that was taken to Kabul and the passengers freed after India shamefully released Kashmir terrorists. Mysteriously, the hijackers disappeared. So far, the ISI’s plan was performing brilliantly, but as the poet Burns said, men’s plans often go wrong. What went wrong for the ISI was that the Taliban gave sanctuary to Osama Bin Ladin, who was more obsessed with Israel, Palestine and the US than J&K.

I’d take option 3 – we need to have a clear resolution of this mess, and no half-hearted measures. That will be the only way to stop Islamic terrorism in South Asia, one that directly affects the US.