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!”         

One of Us?

Anchorage to Denali - photo by JoAnn Sturman

by Scott Sturman

As the only conservative in America whose favorite magazine is the New Yorker, I long ago stopped reading the editorial page.  Unlike the op-ed page, which reminds me of a high school valedictorian’s commencement speech proclaiming how their generation will right every wrong in the world, the articles are informative, entertaining, and well written.

Like many in my medical group I share the view there is too much waste in medicine, which is often exacerbated by needless regulations which make our jobs more difficult.  As an example, we are forced to discard perfectly safe and effective drugs which are not only scarce but expensive.  The insanity reminds me of my experience in the Air Force in 1973 when the nation was in the throes of a fuel shortage.  With cars backed up for miles at service stations, we flew so many hours that our butts cried for relief.   Even without a valid mission, Lt. Colonel Michaels ordered his pilots to bore holes in the sky and waste tons of JP4 for fear if not used, the unit would be allocated less flying time the next quarter.

And then in 1998 some articles began appearing in the New Yorker Magazine written by Atul Gawande, a physician who was also a surgical resident.  How did he have time to churn out these in depth, poignant observations, when at the time most surgical residents considered a hundred hour work week to be short?  Essays followed which discussed clinical problems from a unique, but refreshing point of view and exposed inefficiencies within the health care system which were expensive and extraordinarily wasteful.  Here was an eloquent spokesman for the medical profession and one of us.

After the Presidential election of 2008 Dr. Gawande’s writings took on more of a political slant, and although medical problems and waste were frequent topics, his articles were suffused with comments supportive of national health care.  His solutions to the the health care crisis made no mention of market forces, competition, or health savings accounts, but relied on central control, as he extolled the merits of ObamaCare.  If this bright man, whose success as a journalist was based on exposing inadequacies in the system, why did he virtually ignore tort reform and fraud as contributing causes?  He was no longer a colleague but the voice of socialized medicine.

An author’s background offers clues about personal motivations, and a glimpse at Wikipedia was revealing.  Medical students and residents may have political views, but most are not political activists; there is simply not enough time or resources.  This is particularly the case of general surgery residents, who battle fatigue and sleep deprivation, and extra time is spent collapsed in bed.  Dr. Gawande’s history is unusual in this respect.  As a student he volunteered for the Gary Hart Presidential campaign and again for Al Gore in 1988.  He took a hiatus from medical school in 1992 to campaign for Bill Clinton and served as a senior advisor for the Department of Health and Human Service in the Clinton Administration before returning to medical training.  During this time he cultivated contacts within the Democratic Party and main stream media which catapulted his career and gave him access to resources far beyond those of the normal surgical resident or practicing physician.

Dr. Gawande is a gifted writer, and he has used his skills to popularize issues in clinical medicine and to propose sweeping changes to the health care system.  However, when it comes to choosing between national health care or private practice medicine, he is one of them and not one of us.   

Rush Limbaugh: Using Pat Hill's Playbook

 Sphinx - photo by JoAnn Sturman

by Scott Sturman

While driving to work a few days after the recent Presidential election, I decided to tune into AM radio and do something I rarely do: listen to Rush Limbaugh’s commentary.  If there ever was a time to be circumspect about Republicans expanding their base of appeal, this was it.  Instead the listener heard a sermon about the necessities of scrupulously adhering to the tenets of conservatism.  One rightly could ask, “Who’s conservatism?”  Rush's ego was palpable, as if he could will the non believers into seeing things his way.  Despite the changing demographics of the American political scene, the movement should stay the course, and if it was unattractive to women, minorities, or youth that was their problem.  The rigidity and absolute reliance on traditional strategies was oddly analogous to the career of Fresno State’s former football coach Pat Hill.

Pat Hill came to Fresno State in 1997 and until his departure in 2011 put the program in the national spotlight.   “Play anyone, anytime, anywhere,” became his mantra. Coach Hill took the Bulldogs to numerous post season bowl games, placed a bevy of players in the NFL, and developed one of the most academically sound football programs in the country.  Yet as the years continued, the win-loss record took a turn for the worse.  Although the team could play competitively at times, all too often mediocre opponents dominated the Bulldogs.  The coach played an old fashioned style which had become predictable, and his adversaries took full advantage of the stereotypical strategies.  Fruitlessly running the ball up the middle and refusing to blitz the quarterback when the secondary was being picked apart became hallmarks of the program and the subject of snide remarks.  The coup d‘ tat came in 2011 when the Bulldogs hosted their arch rival Boise State at home.  At the end of the first half it was Boise 50 - Fresno State 0, and Coach Hill’s fate was sealed.

Fresno State hired a new coach, Tim DeRuyter, for the 2012 season.  He plays the same talented players Hill recruited, but now late in the season the Bulldogs are the favorites to win the conference championship.  Sometimes success is determined by looking at a problem from a different direction and making appropriate adjustments.

Rush Limbaugh has done much to energize the conservative movement and counteract the pervasive influence of an uncontested liberal media.  His vigorous denunciation of national health care and profligate government spending are to be commended.  Until lately Mr. Limbaugh was able to rally voters to the conservative cause, but of late he preaches to the choir and ignores the need to expand the base to voters who are intellectually and emotionally conservative but disagree with the party’s social agenda.

There is an untapped trove of voters for whom the social aspects of conservatism are secondary to concerns about the economy, national defense, health care, and the expansion of the welfare state.  Social conservatives alone cannot resurrect the Republican Party in a national election; their numbers don’t add up and with every succeeding year the goal will prove more ellusive.

Pat Hill now works as an assistant coach for the Atlanta Falcons which has the best record in the NFL.  A new challenge and role gave him the opportunity to once again travel on the road of success.  It’s time for Rush to follow suit and make way for new personalities with fresh ideas.  

 

Tears for Argentina

Inca Trail Peru - photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com

With its plentiful natural resources and well educated work force Argentina, the 8th largest country in the world, should be a picture of stability and prosperity. Argentina is a European society in South America and home to 41 million people of mostly Italian and Spanish descent. Yet due to poor governance the country has bounded from one economic crisis to another with periods of rampant inflation and labor turmoil. The future value the peso, the nation’s currency, is so unsettled that banks will not issue credit cards or underwrite long term mortgages. Owning property or illegally sequestering dollars or Euros abroad is the only safe way to save.

Health care and education are the largest obligations of the government. Both are free and without restriction, and one of the reasons Argentinians joke about the number of unemployed engineers driving cabs in Buenos Aires. As in most countries which offer national health care, the system is tiered with affluent citizens opting for the private option. Less wealthy citizens with political clout such as union workers enjoy preferred benefits. The majority of the people have no choice but to use the national health system, which statistically delivers a mediocre product and remains the avenue of last resort. When citizens have the opportunity to access private care, they elect to do so despite increased cost and personal sacrifices necessary to pay for it.

Ask any Argentinian to name the two gravest problems facing the nation, and corruption and inflation top the list. Graft pervades every level of society, and prevents the country from performing at its potential level of efficiency. There is a general sense of ennui and most are resigned to the fact that it is inevitable and unsolvable. Whatever money remains loses it value at 20% per annum due to expansionist fiscal and monetary policy.

Unions wield enormous power in this country where 92% of the population lives in urban areas. Constant strikes to gain concessions hinder commerce. A good example is Aerolinea Argentina, an incompetently operated private company that is now under government control. It remains one of the worst airlines in the world, requiring huge subsidies and frequently grounded due to work slow downs and bogus excuses to keep the airplanes on the tarmac. When making plans to visit Argentina, seasoned travelers try to book with the world class Chilean airline, LAN, rather than their third world-like competitor.

Despite these nuisances, Argentina is a fascinating and safe place to visit, and unlike much of Latin America sanitation standards are sufficient to preclude the necessity of drinking bottled water. From breath taking Iguazu Falls in the north, to vibrant and fun Buenos Aires, and finally to the splendid national parks in the extreme south, it is a breathtaking country, where visitors are unaware of the turmoil brewing beneath the surface. Our cab driver in Buenos Aires summed up his country’s idiosyncrasies:

“Look at all these young people having fun. You’d never know unemployment in their age group is close to 20%. I’ve lived through five cycles; I’ve been a millionaire and a pauper, and now I’m a sixty year old man driving a cab. The government says inflation is 12%, but I know it’s twice that. Too many crooked politicians buying favors and stealing our money, but somehow we survive. I just hope the tourists keep coming until we discover oil in Patagonia.”

Interview with Hillary Clinton

Puppet Show Kathmandu, Nepal - photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com


Flies In Your Eyes continues a series of interviews with nationally known politicians and international leaders. Since the site is relatively unknown, the interviewees have an opportunity for the first time in their lives to express their true, non scripted opinions without having to pay the price for their candor.

FIYE: Thank you for joining us, Madam Secretary. As you know, this site offers a unique venue where you can express your views without sanction from the national press. First of all, due to the informality of the interview, it has been our experience that the interviewee is more comfortable and forthcoming if titles are ignored, and we address you by the name commonly used within the intimate family circle. What name would you prefer?

Secretary Clinton: The common folk chide me me for my royal airs. Your Highness or Empress appeal to me, but a more measured term like “Your Eminence” will do just fine, young man.

FIYE: Thank you for the compliment, Your Eminence. I am only a year younger than you, and it has been quite some time since I was referred to by a youthful title.

It’s time to begin. During the first Clinton administration, you were acknowledged as the driving force behind the National Health Care initiative. I’ve had the opportunity to travel somewhat and observed that even in the Third World where resources are scarce, the rich and poor alike seek private health care. Whether it’s Kenya, Morocco, Egypt, Peru, or Nepal, the national health care system is avoided whenever possible. What is the allure of national health care when the tract record is so bad?

Your Eminence: Power, pure power. If national health care was so good, politicians would be first to join. That doesn’t happen, because like your friends in the Third World, we know the implications of rationed care practiced by mediocre doctors. Altruism is the frosting we use to cover the cake, but the health system is a multibillion dollar industry; that pays for a lot of political patronage and union support.

FIYE: Let’s change pace and give you a chance to get some issues off your chest. It is not the intent of FIYE to become a steamy novella, but many of our readers are interested in your personal life to better understand the woman behind the face. What attracted you to Bill in the first place?

Your Eminence: He had a bad boy image, but I found him irresistible. When we met, I wasn’t particularly attractive, so I was surprised he took an interest. Women loved Bill, and the man could talk the pants off of a nun. He was clever enough to know if his political objectives were to be met, he needed someone smart and calculating who could channel his carnal energies and direct his career. You don’t find that type of moxie in a sorority at the University of Arkansas.

FIYE: Some of Bill’s amorous energies overflowed the banks from time to time. Do you feel betrayed?

Your Eminence: It should come as no surprise that our marriage is one of convenience. What affection we had for each other has long since faded. We both understand this. Betrayed? Pissed is more like it! I couldn’t care less who or what he sleeps with as long as he doesn’t get caught. He had this thing for “big haired women” in Arkansas but damage control was easy in Little Rock. The Monica tryst in the White House proved again that men think with the wrong head.

FIYE: How about you? Are there any international leaders who attract you?

Your Eminence: Muammar Qaddafi is hot and so charismatic. Take a look at these pictures of him! When I see him ridding a camel or dressed in those beautiful costumes, I am reminded he is everything Bill isn’t - exotic, handsome, extraordinary.

FIYE: What about those pictures of Conde Rice found in his Tripoli compound? When the Colonel, or Camel Master as he preferred to be called, interviewed with FIYE he raved about her.

Your Eminence: Enough! I read the interview. Those pictures were a ruse to protect me from the media. I presented him with a photo album of myself during my last visit, which he promised would never leave his side.

FIYE: That must hurt. Conde is very attractive, brilliant, and younger than you.

Your Eminence: Only seven years. Muammar is not like most men. He values a woman’s mind more than the body.

FIYE: How did Barrack Obama ever win the Democratic nomination in 2008? You had the name, the party machinery, and a lot of money in the campaign chest. Yet, he is President and you are not.

Your Eminence: This may come as a surprise, but I’m not well liked. I can smile, change my hairdo, tone down the rhetoric, and have my friends at CNN tell the voters I’m warm and carrying, but the public is not that stupid. As soon as I looked vulnerable, the donations dried up and a few months later America had its Manchurian Candidate in the Oval Office.

FIYE: You have plane to catch. I hope we can continue the interview at a later time. Is there any chance you’ll run for President in 2012?

Your Eminence: Funny you should ask, and by the way I accept the invitation. George Soros and I are meeting later this month to discuss strategy. His last horse didn’t run too well, did he?

Medical Malpractice in Morocco

Sand Dune in Morocco - photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com

Due to its position on the northwest corner of Africa, Morocco is not a closed, insular culture as one would find on the Arabian peninsula. Arabs, Europeans, and sub Saharan Africans have had a hand in molding this conservative and relatively stable country of 31 million.

The souks of Fez and Marrakech, the quaint sea side town of Essaouira, the rugged Atlas Mountains, and the stark Sahara are fascinating to visit. Yet, as with all travels, it is fruitful to delve under the surface and discover how people provide for their basic needs. Being a doctor, it is interesting to learn how a third world country deals with issues like medical malpractice and access to health care.

Medical malpractice litigation simply does not exist in Morocco where 98.7% of the population is Sunni Muslim. The faithful believe that life’s events are due to Allah’s will rather medical negligence and malpractice. In this religious country it would be futile for a medical malpractice attorney to try to convince a jury that his client was entitled to damages sanctioned and preordained by Allah.

Morocco is a poor country. Of the 227 countries listed in the CIA World Book, it ranks 150 in per capita GDP. The government provides health care services for a nominal fee. One would think free health care would be appealing in a country where resources are thin and every dirham counts. Yet most Moroccans will scrape, save, and defer other needs to pay for private health care services.

This is a reoccurring theme. Public health care in the third world generally tends to be of low quality, highly bureaucratic, and prodding. There are rare exceptions like Communist Cuba, but not unlike those living in Europe where national health care is available, people are willing to make enormous financial sacrifices to obtain higher quality care delivered by the private sector.

These experiences from faraway places should not go unheeded. Tort reform is central to lowering health care costs and improving efficiencies in the United States. Defensive medicine and unreasonable documentation requirements are wasteful and outrageously expensive. In theory national health care sounds like a panacea, but in time even the best conceived systems will degenerate into chaos. The next time a politician paints a rosy picture of government controlled universal health care, open the history book and study the promises made regarding Social Security and Medicare.

Good Bye New England Journal of Medicine

Desert and two Welsh corgis near Moab, Utah. Photo by Sam Sturman

New England Journal of Medicine

To Whom It May Concern:

Is the New England Journal of Medicine trying to become the next Weekly Standard or New Republic? After having supported the magazine for many years, it is time to part ways when a respected medical journal becomes a drummer boy for national health care and devotes as much attention to politics as to clinical medicine.

It is one matter to present a balanced discussion of health issues and quite another to incessantly advocate government controlled health care as the only means to solve the problem. In the months preceding passage of the immensely unpopular ObamaCare plan, pundit after pundit espoused this doctrine in the journal's opinion pages with only a single tepid rebuttal from Senator Charles Grassley.

How ironic the NEJM editorial staff led its readers to believe a federalized program is necessary for cost containment when in its own Case Studies from the Massachusetts General Hospital, no test is too expensive or obscure to diagnose the patient's illness. Perhaps this is the prerogative of elite institutions.

Scott Sturman, M.D.

P.S. The Wall Street Journal recently published a discussion of the crushing financial burden imposed by the Massachusetts universal health care system. For years the NEJM editorial staff denied this would occur. With too much demand and a paucity of supply, it is no wonder the state of Massachusetts and its vaunted academic institutions are strong proponents of national health care and the federalization of their debt. The governor's proposal to mandate physician participation in the Massachusetts health system, thereby tacitly making doctors state employees, should sound the alarm to any doctor who cherishes the freedom to work independently.

Joseph Rago: The Massachusetts Health-Care 'Train Wreck' - WSJ.com

http://online.wsj.com/article/

SB10001424052748704324304575306861120760580.html

By JOSEPH RAGO
President Obama said earlier this year that the health-care bill that Congress passed three months ago is "essentially identical" to the Massachusetts universal coverage plan that then-Gov. Mitt Romney signed into law in 2006. No one but Mr. Romney disagrees.

As events are now unfolding, the Massachusetts plan couldn't be a more damning indictment of ObamaCare. The state's universal health-care prototype is growing more dysfunctional by the day, which is the inevitable result of a health system dominated by politics.
In the first good news in months, a state appeals board has reversed some of the price controls on the insurance industry that Gov. Deval Patrick imposed earlier this year. Late last month, the panel ruled that the action had no legal basis and ignored "economic realties."

In April, Mr. Patrick's insurance commissioner had rejected 235 of 274 premium increases state insurers had submitted for approval for individuals and small businesses. The carriers said these increases were necessary to cover their expected claims over the coming year, as underlying state health costs continue to rise at 8% annually. By inventing an arbitrary rate cap, the administration was in effect ordering the carriers to sell their products at a loss.

Mr. Patrick has promised to appeal the panel's decision and find some other reason to cap rates. Yet a raft of internal documents recently leaked to the press shows this squeeze play was opposed even within his own administration.

In an April message to his staff, Robert Dynan, a career insurance commissioner responsible for ensuring the solvency of state carriers, wrote that his superiors "implemented artificial price caps on HMO rates. The rates, by design, have no actuarial support. This action was taken against my objections and without including me in the conversation."

Mr. Dynan added that "The current course . . . has the potential for catastrophic consequences including irreversible damage to our non-profit health care system" and that "there most likely will be a train wreck (or perhaps several train wrecks)."

Sure enough, the five major state insurers have so far collectively lost $116 million due to the rate cap. Three of them are now under administrative oversight because of concerns about their financial viability. Perhaps Mr. Patrick felt he could be so reckless because health-care demagoguery is the strategy for his fall re-election bid against a former insurance CEO.
The deeper problem is that price controls seem to be the only way the political class can salvage a program that was supposed to reduce spending and manifestly has not. Massachusetts now has the highest average premiums in the nation.

In a new paper, Stanford economists John Cogan and Dan Kessler and Glenn Hubbard of Columbia find that the Massachusetts plan increased private employer-sponsored premiums by about 6%. Another study released last week by the state found that the number of people gaming the "individual mandate"—buying insurance only when they are about to incur major medical costs, then dumping coverage—has quadrupled since 2006. State regulators estimate that this amounts to a de facto 1% tax on insurance premiums for everyone else in the individual market and recommend a limited enrollment period to discourage such abuses. (This will be illegal under ObamaCare.)

Liberals write off such consequences as unimportant under the revisionist history that the plan was never meant to reduce costs but only to cover the uninsured. Yet Mr. Romney wrote in these pages shortly after his plan became law that every resident "will soon have affordable health insurance and the costs of health care will be reduced."

One junior senator from Illinois agreed. In a February 2006 interview on NBC, Mr. Obama praised the "bold initiative" in Massachusetts, arguing that it would "reduce costs and expand coverage." A Romney spokesman said at the time that "It's gratifying that national figures from both sides of the aisle recognize the potential of this plan to transform our health-care system."
An entitlement sold as a way to reduce costs was bound to fundamentally change the system. The larger question—for Massachusetts, and now for the nation—is whether that was really the plan all along.

"If you're going to do health-care cost containment, it has to be stealth," said Jon Kingsdale, speaking at a conference sponsored by the New Republic magazine last October. "It has to be unsuspected by any of the key players to actually have an effect." Mr. Kingsdale is the former director of the Massachusetts "connector," the beta version of ObamaCare's insurance "exchanges," and is now widely expected to serve as an ObamaCare regulator.

He went on to explain that universal coverage was "fundamentally a political strategy question"—a way of finding a "significant systematic way of pushing back on the health-care system and saying, 'No, you have to do with less.' And that's the challenge, how to do it. It's like we're waiting for a chain reaction but there's no catalyst, there's nothing to start it."
In other words, health reform was a classic bait and switch: Sell a virtually unrepealable entitlement on utterly unrealistic premises and then the political class will eventually be forced to control spending. The likes of Mr. Kingsdale would say cost control is only a matter of technocratic judgement, but the raw dirigisme of Mr. Patrick's price controls is a better indicator of what happens when health care is in the custody of elected officials rather than a market.
Naturally, Mr. Patrick wants to export the rate review beyond the insurers to hospitals, physician groups and specialty providers—presumably to set medical prices as well as insurance prices. Last month, his administration also announced it would use the existing state "determination of need" process to restrict the diffusion of expensive medical technologies like MRI machines and linear accelerator radiation therapy.

Meanwhile, Richard Moore, a state senator from Uxbridge and an architect of the 2006 plan, has introduced a new bill that will make physician participation in government health programs a condition of medical licensure. This would essentially convert all Massachusetts doctors into public employees.

All of this is merely a prelude to far more aggressive restructuring of the state's health-care

markets—and a preview of what awaits the rest of the country.

Mr. Rago is a senior editorial writer at the Journal.

New England Journal of Medicine- From Science to Fiction

Death Valley - photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com


The New England Journal of Medicine, arguably the world's premier internal medicine journal, is well know for the series, “Case Records of the Massachusetts General Hospital.” Every week a complex medical problem is examined by a group of brilliant physicians who dissect the case. Using the patient's history, physical examination, and every conceivable laboratory test and invasive procedure, they invariably solve the case and prescribe the proper treatment. No expense is spared in their quest to provide optimal and timely care for the patient.

The editorial page of the Journal is a different story. In years past editorials focused on medical issues such as new drugs and tests, medical ethics, and critiques of antiquated methods which were no longer appropriate for patient care. Several years ago the editorial page expanded dramatically, and the subject matter took on a new flavor – the flavor of politics. Not a week goes by without another essay touting the benefits of national health care, criticizing the influence of physician specialists, and advocating complex government regulated programs on cost containment and reimbursement.

The State of Massachusetts offers universal health care. A greater percentage of its citizens are covered than any other state, but there are serious cost overruns which leave the system unsustainable in its present condition. The Journal strongly supported the adaption of universal health coverage in Massachusetts, and despite the financial difficulties of the state plan, the Journal advocates a similar national program.

Now that the euphoria of establishing the nation's first state universal health care system has subsided, editorial comment has focused on convoluted ways to pay for a program that is experiencing huge cost deficits. The proposed solutions follow these general categories:

• Higher taxes on businesses, employers, and individuals “most able” to pay
• Establishment of boards of experts to allocate revenue fairly among providers
• Independent agencies prioritizing health care options – a euphemism for rationing
• 
  

Striking omissions or subjects receiving scant consideration include:

• Enactment of comprehensive and meaningful tort reform
• Measures to ensure patients assume some individual responsibility for their health
• Programs which allow patients to possess financial leverage when seeking health care

Recent proposals discussed in the Journal question the rational of the fee for service medical model and favor large salaried multi specialty groups. Another recently promoted view is that it is immoral for United States citizens to automatically receive the H1N1 flu vaccination before people in the third world. The expression “we should stand in line with everyone else” was used. Still another stance from this influential magazine openly criticized the number of specialists as opposed to primary care physicians and listed mechanisms to reverse the trend by diverting revenue from specialists to primary care. Similar efforts by the Clinton Administration to change this ratio by training fewer specialists caused severe shortages in specialty care for over a decade. For these philosophies to become policy, extensive government control is required – solutions which seemingly rest comfortably with the editorial staff of the New England Journal of Medicine.

Case # xxxx - 2020 “A 45 year-old Woman with Rheumatoid Arthritis and Diminished Level of Consciousness” The patient presented with a heart murmur, renal failure, and diminished level of consciousness. She had no urine output for two days.

Physician #1 (Visiting Professor): This case involves a critically ill patient with multiple system failure. In addition to routine laboratory I would order an echocardiogram and an MRI of the head. Due to the complexity of the case it will be necessary to notify the appropriate specialists.

Physcian #2 (Staff): I'm sorry, doctor. There are few specialists in Massachusetts. Also, the Medical Resource Board does not allow physicians to order specialized tests without their approval. This condition is waived, of course, if the patient is a politician. A complete blood count, urinalysis, EKG, and chest X-ray should provide adequate information to solve the case.

Physician #1 (Visiting Professor): How are you going to obtain a urinalysis if the patient has not urinated for 48 hours?