Tim Tebow and Hospital Administrators

Woman in Kathmandu - photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com

Several years ago the board of trustees at a local hospital decided a change of administration was in order. The hospital was acknowledged to be the best in the Central Valley, but like an owner who will be only content once he wears a Super Bowl ring, it was time to hire a new coach who could deliver. True, like many other hospitals there were some economic difficulties, but it was home to the area’s most competent physicians and a highly motivated hospital staff. It took the new administrator and his team less than five years to destroy the hospital’s reputation, undermine its financial integrity, and leave it in a position where it will take years to recoup some semblance of former glory.

Too many hospital administrators lack leadership ability. They exhibit many if not all of S.R. Oberst’s unleadership principles. Put them in the woods in a survival situation and few of us would follow them to the latrine even if suffering from diarrhea. Their resumes brim with accolades and achievements, but strip away the verbiage and few of them have any idea how to motivate the medical staff and employees. They should take a lesson from Bronco quarterback, Tim Tebow.

Tebow is a raw talent with unorthodox skills. He makes mistakes and throws a wobbly spiral, but he is a proven winner. He may stink up the gridiron for 55 minutes, but watch out for the last five! How does he do it? Despite his humility and fierce competitiveness, the secret lies in his ability to motivate others. He plays for a team with mediocre talent, but the players give a 100% effort throughout the entire game. They believe in him and feel each one of them is an integral part of the team. They may be behind by two touchdowns with four minutes left in the game, but in their minds victory is at hand.

Suppose Tim Tebow was a hospital administrator. He would not sit in his office with the door closed and ruminate about how to embellish his career or initiate harebrained schemes without understanding the problem. He would be seen at all hours throughout the hospital, talking with everyone from janitor to physician to learn firsthand how to improve the organization. It is called charisma, a lost art in today’s corporate world. Stuffed shirt unleaders pooh pooh it, but it is highly effective and employees love it.

Tebow leads by example and does not expect any teammate to do anything that he would not do himself. This is in sharp contrast to administrators whose leadership styles emulate either wall flower Wally Cox or pillager Genghis Khan. For these “wanna be” leaders, tune into the Bronco-Patriot game this weekend. It will be a tough contest for Denver, but even if football doesn’t make sense, there is a lot to learn by watching #15.

After Two A.M.

Rice paddies in Nepal - photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com

Climbing out of bed at two A.M. to drive to work brings a number of unrelated thoughts to mind:

Where am I?

What time is it?

Where are my clothes?

If I work all night, I’m going to be a zombie and may miss my kid’s game this evening.

What surprises lay in wait with this emergency surgery?

The IRS and State of California will get half of my pay.

What about the guy who is sleeping tonight with his pregnant girlfriend and won’t work tomorrow because he makes more on welfare than picking peaches on the farm?

If tonight’s patient doesn’t have any money, why is he entitled to sue a Good Samaritan for malpractice?

Perhaps I should feel guilty about these selfish thoughts, but as another tax season approaches I am reminded of people who perpetually take from the system and survive due to the generosity of those who are willing to get out of bed at two in the morning.

One wonders how many chances a heroin addict enrolled in a methadone rehabilitation program should receive, when he cannot resist the temptation to inject his beloved drug into a vein on his diabetic ankle. A life threatening infection ensues requiring multiple procedures which includes cardiac surgery when one of the heart valves is destroyed. The bill swells to hundreds of thousands of dollars and is paid by either the taxpayer or the hospital. It is difficult to envision any scenario where this is a prudent method to spend scarce health care dollars.

Personal injury lawyers dispute tort reform is an important part of health care reform, but personal experience teaches otherwise. Many years ago a neurosurgeon and I were called at two in the morning to care for a young man with massive head trauma. The patient suffered from a known seizure disorder but refused to take medication. He was standing high on a fifteen foot ladder while changing a light bulb. As luck would have it, he seized and fell head first on the cement floor beneath the ladder. He was found unconscious and transported to the hospital where he was diagnosed with a massive cerebral hemorrhage. Emergency surgery proceeded as well as could be expected, but the patient died two days later. Two months later the surgeon, the hospital, and I were sued for wrongful death. The case was meritless and eventually lapsed but not without wasting a lot of money and time.

With blood products in short supply, the two in the morning mind wonders if it appropriate to exhaust the blood bank to attempt to save the life of a gang banger shot in the chest by a rival. The dilemma intensifies if the patient shot a policeman and survived the aftermath long enough to reach the operating table. A cancer patient, a patient in shock from a bleeding colon, or a child injured in a motor vehicle accident have a more valid claim to finite, life saving resources.

Rule makers do not get out of bed at two in the morning. Their world is controlled, theoretical, and contemptuous of those who act under stressful conditions where risks and benefits must be considered. I wonder how they would react, if told there was no blood available for their son or daughter; the last pint was transfused to a convict stabbed in a knife fight, who despite the best efforts of the surgical team died in a pool of blood on the operating room table.

Noblesse Oblige

 Photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com

Seeing her “deer in the headlights” expression as she advises the American public to support health care reform legislation before reading the details, makes one wonder if Nancy Pelosi envisions herself as a feudal queen caring for the needs of the peasants. No amount of sarcasm, criticism, or intellectual debate will change her mind. She is one of the wealthiest members of Congress and represents one of the safest Democratic seats in the United States - the 8th District of California which encompasses the San Francisco area. She has had no serious competition for her seat since initially elected in 1987 and typically garners 75% of the vote at election time. So secure is her position that she has not had to debate an opponent since her first race twenty-three years ago. She is bullet proof.

The “Blue Dog” Democrats, a group of fifty-four supposedly conservative leaning Democrats in the House of Representatives, formed an association in 1995 to enhance their clout. Theoretically, they tend to be more socially and financially conservative than their traditional Democratic colleagues, and many represent southern states. The largest financial supporter of the Blue Dog Political Action Committee is the health care industry.

Jim Costa, who represents California's 20th District, and Dennis Cardoza, who represents the state's 18th District, are vulnerable Blue Dog Democrats from the Central Valley. One has to question the label “Blue Dog” in their case. The title provides more political cover than an accurate description of their voting tendencies. Both could be more accurately described as “Pelosi's Dogs”. Cardoza has voted for Obama-Pelosi sponsored legislation 96% of the time compared to Costa's 93%. The only time they cannot be counted on to vote like Barney Frank or Maxine Waters is when legislation involves allocation of federal water to their intensively farmed congressional districts.

With her great wealth and uncontested power, it is a small matter for the 70 year old Pelosi to demand Cardoza and Costa take the fall. It is really quite painless. Drink the Kool-Aid, boys. There is no need to read the 2000 pages of proposed legislation. Just like the American people, they can take her word for it and find out what they voted for at a later date.

ADDENDUM:

Yesterday the Catholic Health Association which represents Catholic Hospitals endorsed the Obama health care bill being debated in the House of Representatives. The executive director cited the legislation “isn't perfect” but represents a “major first step.” The message could not be more clear: pass anything even if it is deeply flawed. Imagine a housing contractor building an inferior building, a surgeon performing only half of a required operation, or a teacher telling the class a 50% grade is perfectly acceptable. As long as one makes an effort, the results are inconsequential.

In the larger perspective the issue is about the federalization of debt. States such as California which have not prudently managed their resources have a great deal to gain by having the federal government pay their Medicaid obligations. The losers are the states which have managed their finances wisely and will have to pay for California's ineptitude and, of course, the next generations who will have to pay for the massive amount of debt accrued by this latest spending spree.

RX: Fighting Back

Morocco - photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com


"I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything – except the desires of the doctors."
Ayn Rand Atlas Shrugged

One fact is plain: The health care system cannot function without physician participation. Every part of the machine – hospitals, drug companies, medical equipment manufacturers, and patients depend on one profession. Ours is an occupation which requires 7 to 12 years of extensive training after college and then several more to hone clinical skills. We cannot be replaced easily.

Those of us in private practice deliver the bulk of physician services to the country. Our responsibilities not only include our patients, but as business people we provide for our employees and purchase goods and services from community merchants. Implicit in this contract is the willingness to work long hours which often include weekends, nights, and holidays.

The current health care legislation proposed by Congress is supported only by a minority of Americans and its physicians. Organizations like the American Medical Association, whose name far out weighs its level of support among physicians, are used by politicians and the media to distort the manner in which most doctors view the subject. Although most Americans agree the current system is too expensive, they similarly concur this legislation does not solve the problem. Despite these misgivings, the Congressional leadership is intent upon driving a bad idea down our throats.

Many physicians assume it is a forgone conclusion that this blatant attempt to control the health industry is inevitable. We complain privately and with our colleagues, hoping our national organizations will broker a better deal for our individual specialties. For fear of being publicly criticized, we find ourselves in a moral predicament where we are afraid to act decisively to reverse the process. Yet I would argue it is unethical to passively allow bad legislation to become law. Congressional leaders act boldly without fear of recriminations, because they sense our profession is politically complacent.

Barring a referendum at the ballot box, our only recourse at this juncture is to periodically withhold all but emergency services until the country focuses its attention more clearly. We physicians agree costs must be controlled, and patients should have portability of care without exclusion for preexisting medical conditions, but not without tort reform, major changes in the insurance industry, and some patient responsibility for unhealthy lifestyle choices. It is time to protect the independence of our profession, our patients, and our employees by demonstrating our lack of confidence in Congress.

The Congressional leadership will resort to any measure to pass 2000 pages of rules and regulations as quickly as possible. As previously witnessed, bribery, extortion, false promises, and overly optimistic financial projections can be expected. Their arrogance and disdain for the wishes of the voters they represent are without limits. Many of them will have to face an angry electorate this coming November, but until then it is up to the doctors to thwart their mischief.

2000 Pages and Counting

Limestone Caves Phuket, Thailand - photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com

“The only task governments perform consistently well is spending money.” 2nd Lt. W.R. Priskna 1973

I cannot remember reading a novel over two thousand pages long, but in a matter of months the Democrats have written health care reform legislation whose size dwarfs War and Peace. The tome is a morass of complicated rules which attempts to control every aspect of health care from the cradle to the grave. Yet not surprisingly and despite the seemingly rigorous detail of the plan, the solution is flawed. Only feeble efforts are proposed to enact meaningful tort reform and direct individuals to seek healthy lifestyles. These glaring oversights define the philosophical bridge dividing professional politicians and the citizens they represent. No where in the liberals' reform debate does one find an alternative where the consumer of health services is preeminent.

Both private and government insurance programs are the primary causes of exploding health costs. In insulating the patient from the economic realities of using health care services, no effective mechanism is in place to control costs. Services are offered independent of financial repercussions. Until patients have primary control over expenditures, costs will continue to escalate.

There is a strong correlation between the cost of health services and the use of insurance to pay for them – a simple fact that is ignored in the current health care debate. Ironically, all recently proposed solutions are driven by the use of expanded insurance services to pay for health care. Since 1965 a strong correlation between the cost of health care and the use of insurance can be demonstrated. In 1965 44% of health care was paid from out-of-pocket sources, while 35% relied on private and federal insurance. In the mid 1980's total health costs and the use of insurance to pay for it began to accelerate upwards. By the mid 1990's the slope of these curves inclined steeply upward and continued until the present time. By 2006 12% of expenditures were paid out-of-pocket while 80% were reimbursed by federal, state, and private insurance sources. An excellent summary of these statistics can be found in the Rand Corporation's report:

http://www.randcompare.org/current/dimension/spending

Rather than introduce a two thousand page law which enlarges the scope of institutions that are responsible for the surge in health care costs, consider a document 1% of its size bereft of mandates and focusing on the patient as the final arbitrator of health expenditures. The vehicle which can deliver affordable care is the Health Savings Account (HSA) model which restores an out-of-pocket mentality to the payment system. Inherent within the HSA is a necessary feedback mechanism whereby the patient spends cash money from their account for medical supplies and services and assumes an element of financial risk in the decision process. The HSA is funded with pretax dollars by the individual or employer and is linked to a high deductible catastrophic insurance plan whose primary purpose is to protect against large, unpredictable expenses but not as a source of payment for day to day needs. Patients are intimately involved in the gamut of health care economics - bargaining for services, electing to use generic as opposed to higher priced drugs if there is no appreciable difference in efficacy, deciding whether an emergency room visit is appropriate if they can wait to see their doctor in the office, taking an active part in preventative medicine, and dealing with scores of other health related issues.

The HSA is funded on a annual basis. If funds are remaining at year's end, then they are rolled over into the next year without penalty. At their discretion account owners are permitted to invest account assets without a tax burden on profits. At age sixty-five the fund rolls over into an IRA to be used for other retirement expenses.

Life expectancy in the United States rose from forty-seven years in 1900 to seventy-four years in 2000. These advances are in large part due to preventative medicine: vaccinations, improved sanitation, healthy diets, moderation of alcohol consumption, and smoking abatement. Although smoking rates in the country have dropped, some of the dramatic gains in longevity are being eroded by the health risks associated with obesity. By 2020 it is predicted 45% of all Americans will be obese. The added cost due to diseases associated with this preventable problem will reach the billions of dollars. Compounding the problem are government sponsored food stamp programs which allow recipients who are already at high risk to purchase any food product irrespective of its caloric content or nutritional value. (www.fliesinyoureyes.com Feeding Obesity). No amount of cajoling or public service announcements will reverse the trend. The HSA model which places an element of financial risk into lifestyle choices is the only direct link between practicing sound preventative medicine and receiving an immediate tangible benefit for doing so.

Well intended social programs invariably become larger and more expensive than originally intended. Medicare is a case in point. As part of Lyndon Johnson's Great Society program, Medicare was signed into law in 1965. At that time the Part B premium was $3 per month. In 1972 the program was expanded to cover disabled persons under 65, patients with end stage renal disease, and some physical therapy, chiropractic services, and speech therapy. The Supplemental Security Income (SSI) program was added for the elderly and disabled poor who automatically became eligible for Medicaid. By 1984 federal employees, including the President, members of Congress, and the federal judiciary became covered. More coverage of services ensued and by the year 2000 the Part B premium had risen to $45.40 per month.

Just this week the Senate proposed expanding the number of Americans eligible for Medicare by lowering the age limits for coverage. Despite dire warnings about the program's oppressive costs which may put Medicare in further jeopardy, the Democratic leadership seems intent upon providing universal health care at any cost. If Medicare's forty-four year experience provides any lessons, it is the expense of mammoth federally run programs always will exceed the optimistic projections of politicians who advocate them.

By 2008 Medicare insured 45 million people. The program deals with an array of patient populations including a small subset who use most of the services. The dilemma concerns the moral responsibility to properly care for the elderly without bankrupting the system.

* One percent of the population consumes 30 percent of the country's health care expenditures – nearly half of these are elderly.
* About 30% of Medicare payments are expensed in the last year of life;
* 12% of all Medicare payments are made in the last month of life
* 10% of Medicare patients account for 70% of the Medicare budget.
* 44% of Medicare patients die in hospital, but there is a vast difference between states: 20% in portions of the West and Northwest but 50% in the South and East.
* The percentage of Medicare payments made in the last months of life has changed little as technology has advanced.

The HSA model can be applied to Medicare as well as private patients. With ever increasing costs and an aging population the health delivery system is destined to implode into a mire of rationed care. When the system reaches over capacity patients will lose many of the options taken for granted and the access to timely care. To avert this unpalatable scenario they must be willing to help manage their own health expenses in order to restore the system to solvency. Waste and the potential for fraud are inherent with government run programs and divert tens of billions of dollars away from patient care. The 2008 federal budget for Medicare and Medicaid was $682 billion or 23% of all federal expenditures. It is conceivable to imagine government agencies dispensing this astronomical sum but quite another matter to assume it is done in a prudent fashion. Until patients routinely examine their explanation of benefits rather than deposit them in the waste basket, there will be no effective manner to check abuse. History provides valuable lessons, and it clearly demonstrates the over reliance on insurance has put us into this mess.