Health Care

The crisis of the intellectual

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I was directed to an excellent post by Walter Russell Mead today. It is on the subject of the American social model and the coming era of tumultuous social unrest as the old welfare state model collapses. Europe is already seeing this collapse as nations like Greece face bankruptcy and England deals with the consequences of severe cutbacks in social spending to avoid it.

The US is facing similar economic consequences if the level of spending is not addressed soon. The 2010 elections show that the people recognize the crisis but the “political class” seems less concerned.

“It’s telling to note that while 65% of mainstream voters believe cutting spending is more important, 72% of the Political Class say the primary emphasis should be on deficit reduction,” Rasmussen said.

“Deficit reduction” is code for raising taxes. Spending is heavily embedded in the culture of the political class.

Mead is concerned that the intellectual demographic, those with advanced degrees and careers denominated by thinking rather than doing, is unable to cope with the new situation.

There’s a lot of work ahead to enable the United States to meet the coming challenges. I’m reasonably confident that we remain the best placed large society on earth to make the right moves. Our culture of enterprise and risk-taking is still strong; a critical mass of Americans still have the values and the characteristics that helped us overcome the challenges of the last two hundred years.

But when I look at the problems we face, I worry. It’s not just that some of our cultural strengths are eroding as both the financial and intellectual elites rush to shed many of the values that made the country great. And it’s not the deficit: we can and will deal with that if we get our policies and politics right. And it’s certainly not the international competition: our geopolitical advantages remain overwhelming and China, India and the EU all face challenges even more daunting than ours and they lack our long tradition of successful, radical but peaceful reform and renewal.

No, what worries me most today is the state of the people who should be the natural leaders of the next American transformation: our intellectuals and professionals. Not all of them, I hasten to say: the United States is still rich in great scholars and daring thinkers. A few of them even blog.

His concern is that the intellectuals seem caught in a mind set that goes back to the 19th century and the Progressive Era.

Since the late nineteenth century most intellectuals have identified progress with the advance of the bureaucratic, redistributionist and administrative state. The government, guided by credentialed intellectuals with scientific training and values, would lead society through the economic and political perils of the day. An ever more powerful state would play an ever larger role in achieving ever greater degrees of affluence and stability for the population at large, redistributing wealth to provide basic sustenance and justice to the poor. The social mission of intellectuals was to build political support for the development of the new order, to provide enlightened guidance based on rational and scientific thought to policymakers, to administer the state through a merit based civil service, and to train new generations of managers and administrators.

It’s interesting that one of the comments, a lengthy one, exactly restates this issue but supports this model and argues with Mead that it is still superior.

Second, there are the related questions of interest and class. Most intellectuals today still live in a guild economy. The learned professions lawyers, doctors, university professors, the clergy of most mainline denominations, and (aspirationally anyway) school teachers and journalists are organized in modern day versions of the medieval guilds. Membership in the guilds is restricted, and the self-regulated guilds do their best to uphold an ideal of service and fairness and also to defend the economic interests of the members. The culture and structure of the learned professions shape the world view of most American intellectuals today, but high on the list of necessary changes our society must make is the restructuring and in many cases the destruction of the guilds. Just as the industrial revolution broke up the manufacturing guilds, the information revolution today is breaking up the knowledge guilds.

He goes on to criticize medicine as a guild but I think he is unaware of the rapid changes going on in medicine today. The image of the family GP is quickly shifting to the multispecialty group with primary care provided by nurse practitioners and physician assistants. Those who want a personal relationship with a primary care physician, or even a favored specialist, will increasingly be required to pay cash for the privilege as many doctors who want to continue this model of practice are dropping out of insurance and Medicare contracts because of the micromanagement and poor reimbursement.

In most of our learned professions and knowledge guilds today, promotion is linked to the needs and aspirations of the guild rather than to society at large. Promotion in the academy is almost universally linked to the production of ever more specialized, theory-rich (and, outside the natural sciences, too often application-poor) texts, pulling the discourse in one discipline after another into increasingly self-referential black holes. We suffer from ‘runaway guilds’: costs skyrocket in medicine, the civil service, education and the law in part because the imperatives of the guilds and the interests of their members too often triumph over the needs and interests of the wider society.

Almost everywhere one looks in American intellectual institutions there is a hypertrophy of the theoretical, galloping credentialism and a withering of the real. In literature, critics and theoreticians erect increasingly complex structures of interpretation and reflection while the general audience for good literature diminishes from year to year. We are moving towards a society in which a tiny but very well credentialed minority obsessively produces arcane and self referential (but carefully peer reviewed) theory about texts that nobody reads.

Once again, costs in medicine are a subject by themselves but the solution does not lie in controlling doctors’ incomes. With respect to the academic institutions, I have personal experience here and will describe some of it. The Humanities have been hollowed out by a trend to both politicize and to leave the subject behind as “critical thinking” goes on to analysis that has little to do with it. The Sokol Hoax is but one example.

The Sokal affair (also known as Sokal’s hoax) was a publishing hoax perpetrated by Alan Sokal, a physics professor at New York University. In 1996, Sokal submitted an article to Social Text, an academic journal of postmodern cultural studies. The submission was an experiment to test the magazine’s intellectual rigor and, specifically, to learn if such a journal would “publish an article liberally salted with nonsense if it (a) sounded good and (b) flattered the editors’ ideological preconceptions.”[1]

The hoax precipitated a furor but did not result in much improvement in such publications. My daughter had personal experience when her freshman courses in English Composition and American History Since 1877 both contained numerous examples of political and “social justice” alteration of the subject matter. For example, she was taught that the pioneers in the west survived by “learning to live like the Native Americans.” The fact is that the pioneers were mostly farmers and ranchers and the Native American tribes of the southwest were hunter gatherer societies who did not use agriculture or animal husbandry. She was also taught that the “Silent Majority” of the 1960s were white people who rejected the Civil Rights Act of 1964. Thus they were racists. Even Wikipedia, no conservative source, disagrees:

The term was popularized (though not first used) by U.S. President Richard Nixon in a November 3, 1969, speech in which he said, “And so tonight—to you, the great silent majority of my fellow Americans—I ask for your support.”[1] In this usage it referred to those Americans who did not join in the large demonstrations against the Vietnam War at the time, who did not join in the counterculture, and who did not participate in public discourse. Nixon along with many others saw this group as being overshadowed in the media by the more vocal minority.

She has since transferred to another college.

The foundational assumptions of American intellectuals as a group are firmly based on the assumptions of the progressive state and the Blue Social Model. Those who run our government agencies, our universities, our foundations, our mainstream media outlets and other key institutions cannot at this point look the future in the face. The world is moving in ways so opposed to their most hallowed assumptions that they simply cannot make sense of it. They resist blindly and uncreatively and, unable to appreciate the extraordinary prospects for human liberation that this change can bring, they are incapable of creative and innovative response.

I think this is the source of the “media bias” so prominently referred to by the Right and by many who are not politically focused. This is why talk radio and Fox News have been such huge successes to the consternation of the political class and their supporters. Charles Krauthammer famously said, “Rupert Murdoch (owner of Fox News) found a niche market that contained 50% of the population.”

The Tea Parties are another manifestation of the frustration of the general population with the political class but also with the intellectual class that seems to be wedded to the first. The university community is, at least in the non-science segment of it, increasingly isolated from the concerns of the society that supports them. CalTech has for many years had a Humanities program to expose science and engineering students to culture. Unfortunately, a student in a large university will find much less culture and much more politics in Humanities departments these days.

A couple of other blog posts are worth reading on this subject. One is here and the other is here. They are both worth reading in full.

The Obama care runaway train.

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There is talk of repealing Obamacare if the Republicans take over Congress on November 2. Of course, that is unlikely with President Obama ready to veto any repeal legislation. “OK, we will defund it,” is the response. I doubt anyone realizes how fast this is moving and how difficult it will be to alter the course of this program.

A week ago, I posted on my blog a set of new rules that are being implemented for physician reimbursement. I review workers compensation cases as a part time job. The company that employs me has now come out with a new line of business to review cases for Obamacare. I have been asked if I would be willing to review cases on a 24 hour timeline. This includes weekends. I have spent 40 years reviewing cases for Medicare and the state medical boards for poor care. Now, I am being solicited to do concurrent review on a 24 hour basis for healthcare. I do some concurrent review for workers comp cases but the timeline is usually 3-5 days. Why weekends ? Does this mean that care cannot be provided without approval ?

The pace of change is breathtaking. Today, the Wall Street Journal explains.

A wave of consolidation is washing over the health markets, and the result is going to be higher costs.

The turn toward consolidation among insurance companies is not new, and neither is it among doctors, hospitals and other providers. Yet the health bill has accelerated these trends, as all sides race to anticipate and manage political risk and regulatory uncertainty. This dynamic is leading to much larger hospital systems and physician groups, and fewer insurers dominated by a handful of national conglomerates. ObamaCare was sold using the language of choice and competition, but it is actually reducing both.

The first surge will come among the 1,200 insurers doing business in the U.S., given that a major goal of ObamaCare is to convert these companies into de facto public utilities. Those regulations are now being written—and once they’re up and running some medium-sized carriers will collapse under the new mandates and higher overhead. State insurance commissioners warned the Administration this month that “improper or overly strident application . . . could threaten the solvency of insurers or significantly reduce competition in some insurance markets.” They also implied that bankruptcies are likely.

With these headwinds, investors and Wall Street analysts are now predicting a lost decade for health insurance stocks. But it may be more accurate to say that there will be a lot of losers and some very big winners. Mergers and acquisitions will increase dramatically once companies get a better look at the regulation and figure out the valuation of M&A targets. Larger carriers will swallow smaller ones quietly before they fail.

The pace of change is far more rapid than is appreciated.

Across the country, providers are building giant hospital systems and much tighter doctor alliances like multispecialty groups to get out ahead of a concept known as “accountable care organizations,” or ACOs. To modernize the delivery of medical services, ACOs would encourage doctors to work in teams to use resources more efficiently, streamline treatment and improve quality. The model is the Mayo Clinic and other large integrated systems.

The Mayo Clinic has concluded that it cannot afford to treat Medicare patients. The Phoenix branch of the Clinic has already informed patients that they will accept no more Medicare. The model does not think it will work.

At the moment ACOs are only a gleam in some bureaucrat’s eye, and no one has a clue how they’ll operate in practice until the government releases a working regulatory definition next year. Yet the percussive effects are already being felt across medicine.

Hospitals are now on a buying spree of private physician practices in the rush to build something that will qualify as an ACO. Some 65% of doctors who changed jobs in 2009 moved into a hospital-owned practice, while 49% of doctors out of residency were hired by hospitals, according to the Medical Group Management Association. In its 2010 census, the American College of Cardiology reports that nearly 40% of private cardiology groups are currently integrating with hospitals or merging with other practices.

I spent a few minutes researching the doctors who appeared in white coats to support Obamacare last spring. Those who really were doctors were all hospital employees. Most of them had been hired right out of residency.

Doctors are selling because complying with the ever-growing list of mandates has become more cumbersome; and while staff physicians on salary do gain predictability, they also lose the autonomy of independent practice. The other problem is price controls in Medicare, which are about 20% below private payments for doctors and 30% lower for hospitals. Hospitals are also scooping up practices to lock in referral sources and make up for ObamaCare’s Medicare cuts. As it is, two-thirds of hospitals lose money today on Medicare inpatient services, according to Medicare.

This is an impossible situation and the Medicare patient will become indistinguishable from the Medicaid patient, a burden on the system to be treated by “physician extenders.”

The changes are coming like a runaway train and they will change American medicine irreversibly. Private medicine cannot afford to care for the discounted Medicare patients. Obamacare will convert private care to Medicare. Every one will be a charity case except for the gentry class that votes for Obama. University Hospital physicians may feel that they are immune to these changes but it has been known for 50 years that the value of salaried university physicians is directly related to the income of private physicians. In fact, the university physician has no overhead but they can always tell the administration that they can leave and earn as much, if not more, and this has given them a lot of power.

When I was in training, my surgical training program had three full time faculty members. Now, the same program has 90 full time members. In the same interval, their success in having graduates pass the American Board of Surgery has declined. That may or may not be significant but the culture of medicine is changing rapidly. Many physicians no longer recommend medicine as a career for their children. What this all means, I don’t know. What I do know is that it is coming very fast and few people realize it.

Medicare optouts

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I subscribe to a physician only web site that has a lot of political items in the mix. It has over 100,000 members, well over, I believe. The subject of dropping out of Medicare, and sometimes from all insurance, is a frequent subject. I thought it might be interesting to see the comments (some of them) to one such post.

I am opting out of Medicare

Last week I stopped seeing new Medicare patients. Today, I decided to opt-out completely. The sign in my waiting area reads:

Dear patients,

As of October 1, 2010, I will no longer accept Medicare insurance due to the harassment and cuts in payments by the federal government. My fees are very reasonable – please feel free to discuss them with me personally. I would love to continue to care for my Medicare patients, just without the federal government telling me how do my job or how much to get paid.

This is just the beginning of the healthcare reform. Please thank your elected representatives and think carefully how you vote in November.

Yours,

EndocrineMD

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The trend to cash medical practice

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Some time ago, I did a post on my own blog about doctors dropping out of Medicare and many quitting all insurance. I really got thinking about this after the American Geriatric Society meeting in Chicago last year. I met a woman geriatrician, the only fellowship trained geriatric specialist in central Iowa. She had quit Medicare. That sounds a bit suicidal if all your patients are Medicare age. What had happened was she was being harassed by Medicare because she was seeing patients too often. Many of them were frail elderly living at home. She dropped out and began charging her patients cash for services. She was making a decent living after a year and was happy with her decision. I don’t know how many realize that geriatrics, as a specialty, is a university subsidized field. There is no private geriatric practice because the doctor can’t survive on what Medicare pays. She tried and had to quit. She is doing it on her own now.

The Weekly Standard has an interesting article this week on this trend. The doctor is not near retirement , as many of the folks I had previously talked to were. It took a lot of guts for him to start out this way and he explains why.

There are a couple of errors in the article and I will point them out.

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Lean practices and starting a trauma center.

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The discussion of the pharmacy reorganization got me thinking of the trauma center that we started in 1979. That was well before I learned about lean practices or the Toyota method but I think we used a number of their principles anyway.

When we started our trauma center, we did something a bit like your pharmacy project. We were a small hospital (120 beds) in a new suburban area with the ocean on one side and national parks and mountains on the other. Orange County narrows down to a triangle which ends at San Clemente where the Marine base begins. We knew the county was going to regionalize trauma. A study had come out suggesting that too many people died because “the golden hour” was lost in trying to get doctors and operating rooms organized, especially at night.

Several large hospitals planned to enter a competition to qualify as centers; one of course, was the UCI medical center. None of them was within 25 miles of our hospital. We didn’t like the idea of seeing the injured patients, some of whom would be neighbors, being taken that far and we looked to see if we could set up a trauma center for our community that would pass muster with the EMS survey team. First we had to see if the hospital and medical staff would support it. My partner and I couldn’t do it alone.

I did a study of the finances of trauma. The stereotype is a drunken insolvent who is stabbed or shot. Our community is located along I-5 where it runs from Los Angeles to San Diego. We are between mountains and the sea. I took the records of all emergency admissions, who went to surgery or who were discharged with a “surgical” diagnosis and who went to ICU. Some of those were general surgery but by using a screen we got down to the trauma cases. I found that 85% of them had some sort of insurance. This was largely because most were auto accidents. Even if people don’t carry health insurance, somebody may have medical benefits with car insurance.

We presented this to the department of surgery and they turned us down flat. The vote was something like 33 to 2. We went to the Board of Trustees. At the time, the hospital was owned by a partnership, one of the dreaded for-profit hospitals. The Board was easily convinced that this was something we needed to do if this hospital was going to grow. Southern California is cursed with many small hospitals and few big ones outside of Los Angeles. I knew a vascular surgery group, of three men, in the San Fernando Valley that went to 12 hospitals. One of the reasons I moved to Mission Viejo was to get out of Los Angeles.

Anyway, we had the hospital on board but not the doctors. The hospital decided to make the trauma center a contract service like the ER. My partner and I would run it. The hospital hired a city planner to draw up a proposal for the county. They gave me a copy when he was finished and it was the size of a Chicago telephone book. I read through it and it sounded like a proposal for a shopping center. I rewrote it. A lot of it was useful, like traffic analysis, but the vast majority didn’t answer the right questions.

Then we had to figure how we could do this and not go broke. There were two of us. We would call other specialists, like orthopedists and neurosurgeons, as needed. That’s how we got around the surgery department. There were grumbles but they faded as the orthopods began to realize that trauma cases paid well, mostly. Then we figured out who is in the hospital at night. The other trauma center candidates all promised to have a surgeon and anesthesiologist in-house 24 hours per day. We could not afford that. We promised that the surgeon and anesthesiologist would arrive within 15 minutes of being called, usually before the victim. The ER doc would be there. That was just as Emergency Medicine was becoming a specialty and our ER docs were GPs.

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