Skin in the Game

 Love in Malibu - photo by JoAnn Sturman

Scott Sturman

John Hancock signed his name boldly on the Declaration of Independence, so King George could not help but see it.  Few know the names of most of the other 56 signatories, much less what happened to them. All were well to do and faced a certain trip to the gallows, if defeated by the British.  As it was, many lost their lives, fortunes, and families during the Revolutionary War in order to gain independence for the fledgling nation.  (See Paul Harvey's video discussing the subject.)  Unlike today’s political class, who live by different rules than those they serve, the signers had skin in the game.
 
I saw a patient yesterday, who doesn’t have skin in the game.  She is on welfare, always has been, and probably always will be.  She’s eating herself to death and costing taxpayers a lot of money as her diabetes and hypertension riddle her body.  In her early 30s, 5 foot 2 inches tall and 260 pounds, she’s substantial but not unusually large for a patient population which grows heftier by the year.  She didn’t seem bothered by the prospect of losing her vision, going to dialysis three days a week until she receives a kidney transplant, or dying long before her time.  The staggering costs incurred to treat diseases caused by over indulgence are the least of her concerns; that responsibility has always been somebody else’s problem.

I’m not a primary care doctor but with her mother in attendance and a few extra minutes at hand before a procedure to treat her diabetic retinopathy, why not talk about losing a pound or two?  Who knows?  Maybe something will click this time around.

“Your high blood sugar and blood pressure are more than just numbers.  Now they are destroying your eyesight.  Your kidneys and heart will be next.  Has anyone ever talked to you about the importance of losing weight?  Just a few pounds can make a difference.”

Before the patient could answer, her mother piped in, “We’ve heard this before.  We don’t believe what you’re saying.  We’re just big people.  It’s genetics.”  Sounding like South Africa’s former President Thabo Mbeke, who denied HIV causes AIDs, her enabling mother had the last word when it came to discussing her adult daughter’s health.

ObamaCare and its end result, socialized medicine, theoretically guarantees equal access to health care.  No line jumping or individual considerations are allowed except for Congressmen, who exempt themselves from the program, the very wealthy, for whom expense is no object, or those with special needs, which are determined by politicians.

Perhaps the primary advantages of the private insurance system is the ability to obtain both emergent and non emergent, high quality care quickly and to maintain a personal relationship with one’s physician over an extended period of time.  The costs to obtain these benefits have spiraled out of control due to a complete cost-demand disconnect, waste, fraud, and a rapacious personal injury industry.  Furthermore, the ultimate “skin in the game” solution, the health savings account model, has not received wide spread support due to its emphasis on personal responsibility and financial prudence.

Imagine shopping in Barrak-o-Mart, a grocery store where you are one of half the customers who have pre purchased every product within the building.  It’s all basic merchandise–nothing fancy but good enough to keep the masses from going to the barricades.  Despite the allure of limitless chocolate chip cookies, potato chips, and sugar laden soft drinks, you pass them by for healthier fare.  Having to return to work in a few minutes, there is no time to while away the hours browsing the shelves or devouring every food sample thrust upon you by obliged employees.  You rush to the check out area looking for an express line, but there is none.  The lines are long, and the checkers work with the speed of Third World bureaucrats.  Half of the customers have two grocery carts brimming with food products selected for sweetness and mega calorie counts.  Forget returning to work on time.  The checkout time is measured more aptly in days or months than minutes.

Beleaguered, but with the cash register finally in sight, the store manager halts your progress and allows two customers with more pressing needs to cut in front.  One resembles the patient described earlier in the article to such a degree that he could be her twin brother.  The other is Senator XX, whose comely assistant is pushing a cart packed with caviar, truffles, filet mignon, and bottles of the finest wine.

“Excuse me, Senator.  Where did you find such bounty?”

“I don’t shop in the same part of the store as you, lad.  Now enough of your pretense, let me through!”         

Medicare Breaks the Bank - Again

Serengeti, Tanzania - photo by JoAnn Sturman

by Scott Sturman

The nearly complete disconnect between cost and demand is the primary reason Medicare is broke.  A surgical colleague shared a story which illustrates the problem. 

Provenge is a FDA approved vaccine used in the treatment of advanced, metastatic prostate cancer.  The drug costs $93,000 and in clinical studies extended life expectancy from 21 to 25 months - a mere four months.

A company representative visited the surgeon at his office and encouraged him to use the product.  A gist of the conversation follows:

“Why should I prescribed Provenge for my patients?”

“It increases life expectancy 20% for patients with advanced prostate cancer.”

“Prostate cancer is an indolent process.  A 20% increase in life expectancy from initiation of treatment sounds impressive, but actually it’s only four months.  It’s a small benefit for a lot of money.”

“The cost is not a problem; Medicare pays every cent.”

“Nearly $25,000 per month for four months seems exorbitant.  Besides, the last four months of life with metastatic prostate cancer are miserable; the patient is generally bed ridden and requires high doses of narcotics to manage the pain.” 

“Imagine what the public would think, doctor, if the newspaper reported your unwillingness to help dying patients in your care from spending a few more months with their loved ones.”

If the cost benefit ratio is unreasonable, then the threat of  exposure to the media as a heartless physician who knowingly deprives his patients of all available treatments may be the most convincing sales strategy.

The surgeon was curious how his patients with advanced metastatic prostate cancer felt about a cancer vaccine.  After explaining the risks and benefits of the treatment, he informed them the drug costs $93,000.

“No way I’m going to pay that kind of money for maybe four extra months, doc.”

“I thought you’d say that, but the drug costs you nothing.  Medicare pays the entire bill.”

“Well ... in that case.”

“Let me ask you another question, while we are on the subject of finances.  If I offered you the choice of $20,000 in cash now or the $93,000 cancer vaccine free of charge, which one would you take?”

“I’d take the $20,000, doc.”

“That’s what everybody else said.  We could save Medicare $73,000, if they would just pony up the cash, and you would forego treatment.”

Vast sums of money are wasted in the Medicare program. Rather than proposing Health Savings Accounts and similar programs which restore financial accountability, ObamaCare regulations undermine them.  As long as there is no link between the specific service and its expense, massive cost overruns and eventual rationing of care are inevitable.

The Modern Physician: Just Another Job

Scott Sturman

fliesinyoureyes.com

Zhangmu (Chinese name), Tibet - photo by JoAnn Sturman

There is a disturbing trend in medicine.  An increasing number of doctors are perfectly content to work for someone else rather for themselves and their own patients.  It is not uncommon for the press to portray those in private practice as out of touch, money driven, and non collaborative.  Conversely, those willing to work as employees are extolled as balanced, tech savvy professionals, whose occupation may as well be a hobby as a calling.  It is as if the well rested, non stressed, feel good physician has ascended to the pinnacle medical profession.  One hopes this new paradigm will be able to handle a life threatening emergency at 3 AM, if they are not too tired, that is.

Parallels abound in the business world, too.  Why subject oneself to the pressures of making decisions day and night, hiring and firing, paying payroll and rent, and maneuvering through a morass of regulations, when simply working for someone else avoids the angst?  As foreign as it may seem to the pampered, dependent class, there are those among us who insist upon being their own boss and enjoy the added responsibility and the pleasures which go along with it.

What is provoking this outburst?  A front page article with the ho hum title, “Today’s Doctors Want More Balanced Lives Than Elders” in Pravda’s local subsidiary The Fresno Bee is the culprit.  The reader is reassured today’s physicians are not forced to work long hours like previous generations, and they can look forward to a career of punching a time clock, all in the name of being team players.  Much of this good news is possible due to the hype and inflated expectations surrounding the electronic medical record and visions of doctors at the patient’s bedside entering data on their iPads.  No need for eye contact or holding a hand, a good bedside manner was always over rated.

There is some data which supports the changing scope of medicine:

• A 2011 survey by the recruitment firm Merritt Hawkins found only 1% of physicians seek a solo practice.

• In 1977 20% of medical school graduates were female.  Now it is 50%.

• As recently as 2005 7% of male doctors and 29% of female doctors worked part time.  Now the percentages have risen to 20% and 44% respectively.

• In 2003 medical residents were restricted to an 80 hour work week with maximum shifts of 16 hours.

Medical schools are selecting for a different type of physician: a physician who clearly has no problem being an employee and who will not have to undergo the rigorous training requirements of prior generations in order to do so.  Young physicians are duped into looking at their noble career as a part time job where early retirement is the norm and empathy and the traditional physician patient relationship are secondary to technology.  In this new world patients are a number, not a name, and their physicians as passionate about their work as a short order cook slapping a beef patty on a toasted bun.

The part time physician mindset contributes to the persistent shortage of physicians; many simply do not practice long enough to justify the length and expense of training.  Talented and qualified as they may be, it is a misallocation of resources to spend 12-17 years in training  and to assume $250,000 - $500,000 of debt, then to decide in one’s 30s or early 40s to throw in the towel.  It is not difficult to understand the insouciance of physicians when it comes to defending their profession, when years of one’s life and hundreds of thousands of dollars worth of investment is cast away like an old pair of shoes.  

To be fair, many young aspiring physicians have the motivation, talent, and confidence to call the shots after completion of their formal education, but whereas my generation had the option of doing so, this opportunity is increasingly more difficult to be found.  The system has been reconstructed to discourage the establishment of independent practices by permitting insurance companies and government agencies to control medical economics and patient access to care.  The mass of paperwork and diminishing reimbursements serve as a powerful disincentive for any physician wishing to practice free of outside interference.  Innovative solutions like medical savings accounts, where the patient maintains control of medical finances and is free to enter into non coercive professional relationships with their doctors, has been stymied at every turn by bureaucrats and the insurance industry alike.   

Ayn Rand talked about the degradation of the medical profession in her book Atlas Shrugged.  When men and women trained in society’s most crucial profession acquiesce to politicians by capitulating to their demands and accepting the premise that others have a right to their services, then the independent, free thinking physician ceases to exist. 

Khasa (Nepali name), Tibet - photo by JoAnn Sturman

   

Eat, Drink, and Be Merry

Piggyback Ride in Nepal - Photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com

One pill makes you larger. And one pill makes you small. Grace Slick 1966

Medical insurance premiums are outrageously expensive. My family subscribes to a health savings account (HSA) with a $4000 individual deductible, which is the closest product to a catastrophic coverage plan available to us. We have no health problems, so until March of this year we still paid the insurance company about $1000 per month to negotiate discounted contracts with health providers in case we need their services. This month the rates skyrocket 20% to over $1200 per month for the same service. With a greater than 95% confidence level the deductible will not be exceeded, the insurance company could not be happier than to serve customers like my family.

A primary reason for these outlandish insurance rates are the high cost of pharmaceuticals, and the public’s over willingness to take pills rather than adjust personal lifestyles. Last year a pharmaceutical company aired a television commercial showing an obese woman dressing for an evening on the town as she primped in front of her bedroom mirror while listening to up beat music. Plenty of food and libation awaited her... but then there was this problem with her diabetes. Fortunately, the advertised product allowed her to check her blood glucose level without a painful pin prick on the finger. Now she was free to take insulin without the slightest inconvenience.

The commercial went beyond describing the merits of the product by implying serious medical conditions need not be bothersome or get in the way of indulgence. When it comes to having fun, weight and caloric intake need not be a concern. Just as the First Amendment guarantees freedom of speech, we have the same right to waive caution and do whatever feels good. The message is clear: If one's blood sugar is too high, there is no need to worry - just take more insulin.

The pharmaceutical industry produces scores of drugs which benefit the public, but in some ways the drugs are too good. They frequently treat the symptoms and not the cause, making it all too easy to ignore the latter. This is particularly true in regard to the country's number one cause of self induced morbidity - obesity. If blood pressure is too high, it is far more convenient to take an expensive drug than lose 30 pounds. If more weight gain ensues, then simply take a second or third blood pressure medication. If diabetes becomes a problem, then an oral hypoglycemic medication is available, and if that is not enough then insulin is the next option. There are plenty of antibiotics to treat a diabetic's high risk of infection. If coronary arteries begin to plug as a result of diabetes and hypertension, there is a virtual pharmacopoeia of remedies. When the kidneys fail, dialysis is at hand. As knees, hips, and backs fail under the strain, they can be replaced or repaired. When signs and symptoms expand, so do costs and patient suffering.

In our practice it is not unusual to see patients who take 15 or more different medications daily. Ingesting pills becomes a way of life, as modern lifestyles demand quick fixes to problems which have been years in the making. For every patient who is over medicated, there are doctors who for varying reasons write prescriptions with little regard to cost or ultimate efficacy. Perhaps it is time to ignore slick drug commercials, watch the calories, exercise more, and ask the doctor what needs to be done to reduce the number of prescribed medications rather than upping the ante.