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  • Where is health care going ?

    Posted by Michael Kennedy on 28th August 2018 (All posts by )

    UPDATE: A new analysis of Obamacare’s role in the conversion of American Medicine to an industry with corporate ethics.

    The health system is now like a cocaine junkie hooked on federal payments.

    This addiction explains why the insurance companies are lobbying furiously for these funds alongside their new found friends at left-wing interest groups like Center for American Progress. The irony of this alliance is that the left-wing allies the insurers have united with hate insurance companies and want to abolish them. The insurance lobby is selling rope to their hangman.

    Hospital groups, the American Medical Association, the AARP and groups like them are on board too. They are joined by the Catholic Bishops and groups like the American Heart Association and the American Lung Association. (If you are donating money to any of these groups you might want to think again.) This multi-billion dollar health industrial complex has only one solution to every Obamacare crack-up: more regulation and more tax dollars.I practiced during what is more and more seen as a golden age of medical care. Certainly the poor had problems with access. Still, most got adequate care, either through Medicaid after 1965, or from public hospitals, many of which were wrecked by Medicaid rules and by the flood of illegal aliens the past 40 years.

    Obamacare destroyed, probably on purpose, the healthcare system we had. It had been referred to by Teddy Kennedy, the saint of the Democrats Party as “a cottage industry.” As far as primary care was concerned, he was correct. What we have now is industrial type medicine for primary care and many primary care doctors are quitting.

    So why is there waning interest in being a physician? A recent report from the Association of American Medical Colleges projected a shortage of 42,600 to 121,300 physicians by 2030, up from its 2017 projected shortage of 40,800 to 104,900 doctors.

    There appear to be two main factors driving this anticipated doctor drought: First, young people are becoming less interested in pursuing medical careers with the rise of STEM jobs, a shift that Craig Fowler, regional VP of The Medicus Firm, a national physician search and consulting agency based in Dallas, has noticed.

    “There are definitely fewer people going to [med school] and more going into careers like engineering,” Fowler told NBC News.

    There are several reasons, I think. I have talked to younger physicians and have yet to find one that enjoys his or her practice if they are in primary care. That applies to both men and women. Women are now 60% of medical students. This has contributed to the doctor shortage as they tend to work fewer hours than male physicians.

    A long analysis of physician incomes shows that 22% of females report part time work vs 12% of males.

    Physicians are the most highly regulated profession on earth. The Electronic Health Record has been made mandatory for those treating Medicare patients and it has contributed a lot to the dissatisfaction of physicians.

    THE MOUNTING BUREAUCRACY
    This “bottleneck effect” doesn’t usually sour grads on staying the course, Fowler finds, but he does see plenty of doctors in the later stages of their careers hang up their stethoscopes earlier than expected. Some cite electronic health records (EHRs) as part of the reason — especially old school doctors who don’t pride themselves on their computer skills. New research by Stanford Medicine, conducted by The Harris Poll, found that 59 percent think EHRs “need a complete overhaul;” while 40 percent see “more challenges with EHRs than benefits.”

    If I remember my arithmetic, that adds up to 99% unhappy with the EHR.

    Most primary care physicians I know are on salary, employed by a hospital or a corporate firm. They are require to crank out the office visits and are held to a tight schedule that does not allow much personal relationships with patients. The job satisfaction that was once a big part of a medical career is gone.

    Posted in Health Care, Medicine, Obama, Politics | 43 Comments »

    Melanoma and Pregnancy.

    Posted by Michael Kennedy on 26th September 2015 (All posts by )

    This is just a brief post to mention that that today’s Daily Mail has an article about a pregnant women with a spreading melanoma. In my book, linked on this site, I have a chapter on melanoma and several stories of patients whose melanoma went wild during a pregnancy. There is no report in the medical literature that supports this connection. Most reports deny any connection, although a few mention some negative prognosis.

    The literature continues to be split on the role of pregnancy in melanoma; however, most recent series show no difference in survival. Multiple studies have failed to show significant effects of female hormones on melanoma cells or on the incidence or progression of melanoma.

    In my book, I describe several cases where pregnancy would “awaken” melanomas that had been removed years earlier or would stimulate worrisome growth in moles. Two of my patients had extensive metastatic melanoma during pregnancy that disappeared after the baby was delivered, in one case with my help. Both women were disease free many years later and neither had another pregnancy.

    How interesting that this young woman has developed metastatic melanoma during pregnancy. I wonder how it will turn out.

    Posted in Health Care, Medicine | 4 Comments »

    A Bleg.

    Posted by Michael Kennedy on 16th June 2015 (All posts by )

    cover.

    I have a new book out on Kindle that is now published. It is called “War Stories: 50 Years in Medicine.”

    I’ve been working on this for 20 years and kept having to revise it as I would put it down and then go back to it after ten years. I finally decided to rework it and publish it two years ago. My students were reading the draft on my laptop while I was editing so maybe it will be interesting.

    It is a memoir of patients. They are all patients’ stories that I have tried to describe accurately and to describe what we did then. Sometimes I screwed up and I tell those, too. Sometimes we did the best we could and we now know better. Some of these cases are still hard to explain.

    Two of them, in the chapter on Melanoma, are about young women who developed major melanoma metastases years after the primary was excised but when they had become pregnant. The melanoma went wild in pregnancy, in one case ten years later. In the other, three years after I had removed the primary, she developed extensive metastases while pregnant. She refused abortion and I thought it would cost her her life. In both cases the melanoma vanished after pregnancy ended. In one case, the woman, last I heard, was free of melanoma 25 years later. The other was free ten years later. The medical literature says pregnancy has no effect on melanoma. Neither ever became pregnant again.

    Another case is an example of the only supernatural near-death experience I have ever heard.

    The book starts when I began medical school in 1961 and describes experiences with patients, including my summer working with schizophrenic men in 1962. I have a series of stories about patients I saw as a student and sometimes intersperse stories from later that are about similar cases and events. One that is amusing, I guess, is about my very first pelvic exam, on a 40 year old prostitute who had just gotten out of prison and enjoyed it thoroughly. I had a dozen student nurses as witnesses. I do have some biography in it but try to keep it to minimum.

    After the first eight chapters, I go on to residency and then finally to private practice. I continued to teach and there are a few of those stories. There is a chapter on ethics including my thoughts on euthanasia and “benign neglect.” Toward the end of my career, I started and ran a trauma center in our community hospital. I also did a fair amount of testifying in court in both trauma cases and some civil cases where I testified for plaintiffs and for defense. I consider it a compliment that Kaiser Permanente had me testify for their defense even though I had also testified against them.

    Anyway, the book is on Kindle and I hope somebody is interested. It has some similarity to my medical history book, which I plan to do a Kindle version of once this one is launched. In this one, I spend some time explaining the diseases in a way that I used to explain to patients and I still do to students. Without some basic understanding, most of these stories would not make sense and I hope the explanations are not too dull. If so, all comments are welcome. If anyone likes it, feel free to post a review on Amazon. Two reviewers from the first book in 2004 told me to let them know if I did another one and I have contacted them.

    If anyone wants to discuss the book here, feel free to add comments.

    Posted in Biography, Blegs, Book Notes, Health Care, Medicine, Personal Narrative | 16 Comments »

    Obamacare = Medicaid

    Posted by Michael Kennedy on 8th May 2015 (All posts by )

    emergency

    I have been interested in health care reform for some time and have proposed a plan for reform. It is now too late for such a reform as Obamacare has engaged the political apparatus and sides have been taken. The Obamacare rollout was worse than anticipated and it was hoped that the Supreme Court would have mercy on the country, but that didn’t happen and it has been the law for two years.

    What has it accomplished ? Well, the forecast drop in ER visits hasn’t happened. It also didn’t happen in Massachusetts when that plan took effect.

    Wasn’t Obamacare supposed to solve the problem of people going to the ER for routine medical problems? We were told that if everyone had “healthcare” — either through the ACA exchanges or through Medicaid expansion — people would be able to go to their family doctors for routine care and emergency rooms would no longer be overrun by individuals who aren’t actually experiencing emergencies.

    As it turns out, Medicaid patients can’t get appointments with physicians.

    “America has severe primary care physician shortages, and many physicians will not accept Medicaid patients because Medicaid pays so inadequately,” said Michael Gerardi, MD, FAAP, FACEP, president of the ACEP.

    Read the rest of this entry »

    Posted in Business, Health Care, Law Enforcement, Leftism, Medicine, Obama, Politics | 7 Comments »

    Why Gruber has to lie

    Posted by Michael Kennedy on 10th December 2014 (All posts by )

    The left does not do economics. They do politics and elections and lying to get past the “stupid voters” but, when pressed, nothing they do qualifies as numerically or mathematically sound. Social Security worked until everyone found the queue and until Congress raided the trust fund in the 90s.

    Obama and the Democrat leaders knew that Hillary made enemies of the insurance companies in 1992. The insurance companies funded devastating TV ads with “Harry and Louise” that cost the Democrats Congress in 1994. Therefore, they had to do what was necessary to get the insurance companies “inside the tent pissing out and not outside the tent pissing in” in Lyndon Johnson’s immortal words.

    Insurance companies have considered health insurance a loser for 25 years now. What they prefer is becoming “Administrative Service Organizations” which administer self funded health plans by employers.

    Corporate benefits include- organizing/ negotiating health insurance, group dental, STD, LTD, life, etc.

    The plan the Democrats came up with, with Gruber’s help, was to make the government the funding entity and pay the insurance companies to run the program. That way everybody is happy, except, of course, the taxpayer. The taxpayer does not like tax increases which would be needed to pay the bills. Therefore the taxpayer has to be fooled.

    The excise tax on high-cost health plans was among the many fees and taxes proposed as offsets to help slow the rate of growth of health costs, particularly premium growth, and finance the nationwide expansion of health coverage. When the Affordable Care Act was signed into law in March 2010, its coverage provisions were estimated to cost more than $900 billion over the next decade, from 2010 to 2019, and were to be paid for by fees and taxes on both individuals and businesses. At the time the health reform bill passed, the excise tax on high-cost plans was estimated to raise roughly $32 billion in revenue over the next decade, or by 2019.

    Without the taxes to pay the bills, the whole plan collapses. At its base, Obamacare is Medicaid for everyone. The employer mandate has been, contrary to the text of the law, postponed as the flaws in implementation appear. If it were to be enforced, there would be a revolution. Basically, Obamacare will destroy the health care plans of the 85% of the population who are satisfied with what they have to enroll everyone in a new program that approximates what Medicaid does. The reason for this is that our betters in Washington have decided that we spend too much on health care. That may even be true. One way to deal with this would be to use a market-based approach that resembles how health care was paid for 60 years ago. I have previously discussed how this worked and how it might be restored.

    Today, the vast majority of Americans get health insurance as a benefit from their employer. How this developed has been discussed at length and began during World War Two. In 2008, John McCain proposed a possible way to disconnect employment, alleged to create “Job Lock” but he lost the election. A hostile analysis of his proposal is here. The McCain campaign’s description is here.

    What became Obamacare is the work of the Democrat staff of Congress when the Democrats had filibuster proof majorities in both houses. The election of Scott Brown in a reaction to the impending passage of the health plan forced them to rush the bill through without amendments before Brown was sworn in January 2010.

    The taxes to fund Obamacare were hidden as “fines and penalties” until exposed by the Supreme Court in its 2012 decision on the constitutionality of Obamacare. All penalties are now taxes. The largest are on employer-funded plans.

    The funding from employee plans is called “The Cadillac Tax which is an excise tax on employer plans that exceed the benefits of Medicaid. The “exchange plans” are increasingly looking like Medicaid, especially in the narrow networks of providers, as doctors are now called.

    As health coverage expands to tens of millions of Americans–through Medicaid expansion in states and the new state health insurance exchanges that will soon begin selling individual health coverage–some Americans with employer-sponsored health coverage are seeing their benefits decrease.

    One of the most significant, and controversial, provisions of the Affordable Care Act is the new excise tax on high-cost health plans proposed to both slow the rate of growth of health costs and finance the expansion of health coverage. The provision is often called the “Cadillac” tax because it targets so-called Cadillac health plans that provide workers the most generous level of health benefits. These high-end health plans’ premiums are paid for mostly by employers. They also have low, if any, deductibles and little cost sharing for employees.

    If this is ever implemented, the Medicaid-for-all nature of Obamacare will become obvious. That’s why it will not happen. The fundamental premise behind Obamacare is not viable. That is why it will fail and the numbers do not add up.

    Gruber can’t say this. All he can do is obfuscate.

    Posted in Elections, Health Care, Law Enforcement, Leftism, Medicine, Taxes | 22 Comments »

    Ebola is now acknowledged to be airborne.

    Posted by Michael Kennedy on 29th October 2014 (All posts by )

    I was just going to add another comment to my previous post on whether Ebola can be airborne but comments are now closed. The CDC has now changed its guidelines on transmission. I linked to Patterico because he has a good post on this. The guidelines are out now as public knowledge.

    “If you are sniffling and sneezing, you produce microorganisms that can get on stuff in a room. If people touch them, they could be” infected, said Dr. Meryl Nass, of the Institute for Public Accuracy in Washington, DC.
    Nass pointed to a poster the Centers for Disease Control and Prevention quietly released on its Web site saying the deadly virus can be spread through “droplets.”

    Why is this stuff coming out in drips (sorry for the pun) like it was Benghazi ?

    “The CDC said it doesn’t spread at all by air, then Friday they came out with this poster,” she said. “They admit that these particles or droplets may land on objects such as doorknobs and that Ebola can be transmitted that way.”

    I won’t duplicate any more of Patterico’s post as he has been on the case nearly as long as I have.

    As for the idiot nurse from Africa who defied authority about quarantine and is suing, she has more trouble today.

    Maine state police were stationed outside the home of Ebola nurse Kaci Hickox Wednesday as Gov. Paul LePage said he was seeking legal authority to force the “unwilling” health care workers to remain quarantined for 21 days.

    The 33-year-old nurse, who has shown no symptoms of the deadly virus, arrived in Maine on Monday after being forcibly held in an isolation tent in New Jersey for three days under that state’s strict new law for health care workers who have recently treated Ebola patients in West Africa.

    There is actually little risk as she is a CDC Epidemiology Fellow with little contact with patient care.

    She is also a lefty Obama supporter.

    It turns out that Kaci Hickox is a registered democrat and Obama supporter who works for the CDC. “The nurse currently quarantined in New Jersey is an employee for the Centers for Disease Control and a registered Democrat with a history of left-wing advocacy,” reports GotNews.com.

    The CDC Epidemiology Fellowships are http://www.cdc.gov/eis/index.html not patient care positions.

    EIS officers are on the public health frontlines, conducting epidemiologic investigations, research, and public health surveillance both nationally and internationally.

    She has an number of published papers on epidemiology that are statistical studies, not clinical care.

    Posted in Ebola, Health Care, Medicine, Politics | 17 Comments »

    Is Ebola airborne ?

    Posted by Michael Kennedy on 13th September 2014 (All posts by )

    Ebola has become an uncontrolled epidemic in Africa. I have previously posted on Ebola.

    UPDATE: A new CDC report has now been provided on precautions. Somebody is worried. The document, itself, is here (pdf)

    Now, we are going to send 3,000 military personnel to Africa to help. I sure hope none of these US people are infected. They did not volunteer for this and the training to protect themselves will take time.

    Now the German epidemiology community has concluded that Liberia and Sierra Leone are lost.

    Jonas Schmidt-Chanasit of the Bernhard Nocht Institute for Tropical Medicine in Hamburg told DW that he is losing hope, that Sierra Leone and Liberia will receive the neccessary aid in time. Those are two of the countries worst hit by the recent Ebola epidemic.

    “The right time to get this epidemic under control in these countries has been missed,” he said. That time was May and June. “Now it will be much more difficult.”
    Schmidt-Chanasit expects the virus will “become endemic” in this part of the world, if no massive assistence arrives.

    With other words: It could more or less infect everybody and many people could die.

    This, of course, is from a German site and our own CDC is unwilling to say it.

    For Sierra Leone and Liberia, though, he thinks “it is very difficult to bring enough help there to get a grip on the epidemic.”

    According to the virologist, the most important thing to do now is to prevent the virus from spreading to other countries, “and to help where it is still possible, in Nigeria and Senegal for example.”

    Of course, it is already in Nigeria.

    In the balance therefore, the probability is that the virus is not airborne — yet — but it is more dangerous than its predecessors. This would account for its ability to slip through the protocols designed for less deadly strains of the disease. It’s not World War E time, but it’s time to worry.

    And: This may be a new strain with more virulence.

    The results of full genetic sequencing suggest that the outbreak in Guinea isn’t related to others that have occurred elsewhere in Africa, according to an international team that published its findings online in the New England Journal of Medicine (NEJM). That report was from April 2014.

    Now, we have more news. From 2012, we know transmission in animals may be airborne.

    While primates develop systemic infection associated with immune dysregulation resulting in severe hemorrhagic fever, the EBOV infection in swine affects mainly respiratory tract, implicating a potential for airborne transmission of ZEBOV2, 6. Contact exposure is considered to be the most important route of infection with EBOV in primates7, although there are reports suggesting or suspecting aerosol transmission of EBOV from NHP to NHP8, 9, 10, or in humans based on epidemiological observations11. The present study was design to evaluate EBOV transmission from experimentally infected piglets to NHPs without direct contact.

    The study of this potential explosive development showed:

    The present study provides evidence that infected pigs can efficiently transmit ZEBOV to NHPs in conditions resembling farm setting. Our findings support the hypothesis that airborne transmission may contribute to ZEBOV spread, specifically from pigs to primates, and may need to be considered in assessing transmission from animals to humans in general.

    Now we have more articles appearing about this.

    The second possibility is one that virologists are loath to discuss openly but are definitely considering in private: that an Ebola virus could mutate to become transmissible through the air. You can now get Ebola only through direct contact with bodily fluids. But viruses like Ebola are notoriously sloppy in replicating, meaning the virus entering one person may be genetically different from the virus entering the next. The current Ebola virus’s hyper-evolution is unprecedented; there has been more human-to-human transmission in the past four months than most likely occurred in the last 500 to 1,000 years. Each new infection represents trillions of throws of the genetic dice.

    If the New York Times is publishing this, somebody is worried.

    Read the rest of this entry »

    Posted in Civil Society, Ebola, Health Care, Immigration, Medicine, Science | 31 Comments »

    What next for health reform ?

    Posted by Michael Kennedy on 26th July 2014 (All posts by )

    It looks to me that the Supreme Court will have little justification for continuing the Obamacare program as it exists. The Halbig decision should kill it off. It is clear that the IRS subsidies to federal exchange subscribers are illegal.

    The only statement anyone has found in the legislative history that addresses this point comes from the Act’s lead author, who affirmed that Congress did intend to withhold tax credits in federal Exchanges. During a September 23, 2009, mark-up of his bill, which ultimately became the PPACA, Senate Finance Committee chairman Max Baucus (D-MT) refused to consider a Republican amendment regarding medical malpractice on the grounds it fell outside the Committee’s jurisdiction. Sen. John Ensign (R-NV) protested, asking how Baucus’ bill could do other things that lie outside the Committee’s jurisdiction, like direct states to create Exchanges. Baucus responded the bill creates tax credits, which are within its jurisdiction, and makes eligibility for those tax credits conditional on states creating Exchanges. Conditional necessarily means that Baucus intended to withhold tax credits in states that did not create their own Exchanges.

    I just don’t see how the Court can ignore that history. The political left has been on a rant about Congressional intent since the decision was announced.

    Read the rest of this entry »

    Posted in Economics & Finance, Health Care, Leftism, Medicine, Politics, Taxes | 10 Comments »

    An Update on healthcare reform.

    Posted by Michael Kennedy on 21st July 2014 (All posts by )

    Cash medical practice or, in the phrase favored by leftists critics, “Concierge Medicine,” seems to be growing.

    Becker is shifting to a new style of practice, sometimes called concierge or retainer medicine. With the help of a company that has been helping physicians make such shifts for over 13 years, he will cease caring for a total of 2,500 patients and instead cut back to about 600. These patients will pay an annual fee of $1,650. In exchange, they will receive a two-hour annual visit with a complete physical exam, same-day appointments, 24-hour physician phone access, and personalized, web-based resources to promote wellness.

    The article suggest that all these doctors choosing to drop insurance and Medicare are primary care. Many are but I know orthopedists and even general surgeons who are dropping all insurance.

    The concierge model of practice is growing, and it is estimated that more than 4,000 U.S. physicians have adopted some variation of it. Most are general internists, with family practitioners second. It is attractive to physicians because they are relieved of much of the pressure to move patients through quickly, and they can devote more time to prevention and wellness.

    Read the rest of this entry »

    Posted in Big Government, Bioethics, Crony Capitalism, Health Care, Medicine, Politics, Science | 23 Comments »

    My health care posts from 2013

    Posted by Michael Kennedy on 2nd January 2014 (All posts by )

    David has a good idea. I often read the archives of my personal blog to see how I did in forecasting the future or understanding the present. A major concern of mine is, of course, health care and what is happening. When I retired from surgery after my own back surgery, I spent a year at Dartmouth Medical School’s center for study of health care. My purpose was to indulge an old hobby. How do we measure quality in health care ? I had served for years on the board of a company called California Medical Review, Inc. It was the official Medicare review organization for California. For a while I was the chair of the Data Committee. It seems to have gone downhill since I was there. First, it changed its name in an attempt to get more business from private sources. Then it lost the Medicare contract.

    Lumetra, which lost a huge Medicare contract last November, is changing its name and its business model as it seeks to replace more than $20 million in lost revenue.
    The San Francisco-based nonprofit’s revenue will shrink this year from $28 million last fiscal year, ending in March 2009, to a projected $4.5 million, CEO Linda Sawyer told the Business Times early this week.
    That’s in large part because it’s no longer a Medicare quality improvement contractor, formerly its main line of work. And in fact, the 25-year-old company’s revenue has been plummeting since fiscal 2007, when it hit $47 million.

    I see no sign that it is involved with Obamacare which is being run from Washington with a state organization that seems no better run than the parent organization.

    Beginning Jan. 1, 2015, the Affordable Care Act no longer will provide federal grants to fund state health exchanges. In addition, California law prohibits using the state’s general fund to pay for the exchange.

    Anyway, for what it is worth, here are the links to the 2013 health posts.

    The Lost Boys

    Alternatives to Obamacare.

    Why the Obamacare Site Isn’t Working.

    Where Healthcare May be Going.

    Conservatives Invented the Mandate; say the Democrats.

    A Critical Insight.

    A Rolling Catastrophe.

    Why Health Care is in Trouble.

    Where Do We Go Now ?

    Building the Airplane During Takeoff.

    Posted in Blogging, Current Events, Health Care, Medicine, Obama, Politics, Systems Analysis | 17 Comments »

    Conservatives invented the mandate; say the Democrats.

    Posted by Michael Kennedy on 28th October 2013 (All posts by )

    The latest meme I’ve noticed on the Obamacare implosion is that the Republicans are to blame. After all, it’s Romneycare, or it’s the idea of the Heritage Foundation.

    In fact, the mandate was promoted by Hillary in 2008 and opposed by Obama. Of course, he doesn’t know much about what is going on so we can understand. In fact, the entire website fiasco, slipped by him, unnoticed.

    President Barack Obama didn’t know of problems with the Affordable Care Act’s website — despite insurance companies’ complaints and the site’s crashing during a test run — until after its now well-documented abysmal launch, the nation’s health chief told CNN on Tuesday.

    Of course he may just rewrite the code himself. After all, he is so talented that he is bored.

    David Remnick, editor of The New Yorker, quotes White House senior adviser and longtime Obama friend Valerie Jarrett: “I think Barack knew that he had God-given talents that were extraordinary. He knows exactly how smart he is. … He knows how perceptive he is. He knows what a good reader of people he is. And he knows that he has the ability — the extraordinary, uncanny ability — to take a thousand different perspectives, digest them and make sense out of them, and I think that he has never really been challenged intellectually. … So what I sensed in him was not just a restless spirit but somebody with such extraordinary talents that had to be really taxed in order for him to be happy. … He’s been bored to death his whole life. He’s just too talented to do what ordinary people do.”

    Oh well, at least we know if we really get in trouble, we have someone who can bail us out. I don’t doubt the comment about him never being challenged intellectually.

    Read the rest of this entry »

    Posted in Big Government, Civil Liberties, Health Care, Leftism, Obama, Politics | 3 Comments »

    Where health care may be going.

    Posted by Michael Kennedy on 23rd October 2013 (All posts by )

    UPDATE: I posted this as much for myself as for others to read. Today, Peggy Noonan weighs in. In case this is behind the paywall, here is her conclusion.

    Even though it’s huge, and those who are reporting the story every day are, by and large, seasoned and have seen a few things, no one seems to know how it will end. Because it’s new territory. Does anyone believe the whole technological side can be fixed quickly? No. The president may eventually accept a brief delay in implementation—it is almost unbelievable that he will not—but does anyone think that the economics of the ACA, the content as set out and expressed on the sites, will flow smoothly, coherently, and fully satisfy the objectives of expanding health-insurance coverage while lowering its cost? You might believe that, but early reports of sticker shock, high deductibles and cancelled coverage are not promising. Does anyone think the president will back off and delay the program for enough time not only to get the technological side going but seriously improve the economics? No. So we’re not only in the middle of a political disaster, we’re in the middle of a mystery. What happens if this whole thing continues not to work? What do we do then?

    This is the Titanic, folks.

    I have watched the failed rollout of Obamacare this past three weeks and wondered where it was going. I have some suspicions. There is a lot of talk about delaying the individual mandate, as Obama did with the employer mandate. Megan McArdle has a post on this today. I think it is too late to fix or delay Obamacare.

    With Nov. 1 storming toward us and the health insurance exchanges still not working, we face the daunting possibility that people may not be able to sign up for January, or maybe even for 2014. The possibility of a total breakdown — the dreaded insurance death spiral — is heading straight for us. The “wait and see if they can’t get it together” option no longer seems viable; we have to acknowledge that these problems are much more than little glitches, and figure out what to do about them.

    She has already described the insurance death spiral. I think it is here.

    Am I exaggerating? I know it sounds apocalyptic, but really, I’m not. As Yuval Levin has pointed out, what we’re experiencing now is the worst-case scenario for the insurance markets: It is not impossible to buy insurance, but merely very difficult. If it were impossible, then we could all just agree to move to Plan B. And if it were as easy as everyone expected, well, we’d see if the whole thing worked. But what we have now is a situation where only the extremely persistent can successfully complete an application. And who is likely to be extremely persistent?

    Very sick people.

    People between 55 and 65, the age band at which insurance is quite expensive. (I was surprised to find out that turning 40 doesn’t increase your premiums that much; the big boosts are in the 50s and 60s.)
    Very poor people, who will be shunted to Medicaid (if their state has expanded it) or will probably go without insurance.

    Levin points out: It is now increasingly obvious to them that this is simply not how things work, that building a website like this is a matter of exceedingly complex programming and not “design,” and that the problems that plague the federal exchanges (and some state exchanges) are much more severe and fundamental than anything they imagined possible. That doesn’t mean they can’t be fixed, of course, and perhaps even fixed relatively quickly, but it means that at the very least the opening weeks (and quite possibly months) of the Obamacare exchanges will be very different from what either the administration or its critics expected.

    The insurance industry is already reacting to Obamacare and this will quickly become irreversible. This article is from September.

    IBM, Time Warner, and now Walgreens have made headlines over the past two weeks by announcing that they plan to move retirees (IBM, Time Warner) and current employees (Walgreens) into private health insurance exchanges with defined contributions from employers.

    The article calls it “maybe a good thing” but that supposes the exchanges will function. What if they don’t for a year or more ? What will health care look like in November 2014 ?

    What happens next — as we’ve seen in states such as New York that have guaranteed issue, no ability to price to the customer’s health, and a generous mandated-benefits package — is that when the price increases hit, some of those who did buy insurance the first year reluctantly decide to drop it. Usually, those are the healthiest people. Which means that the average cost of treatment for the people remaining in the pool rises, because the average person in that pool is now sicker. So premiums go up again . . . until it’s so expensive to buy insurance that almost no one does.

    Will that be apparent a year from now ? I’m sure the administration, and the Democrats, will do almost anything to avoid that. What can they do ? They’ve already ignored the law to delay the employer mandates. It’s too late to delay the individual mandate because individual policies are being cancelled right now.

    Read the rest of this entry »

    Posted in Big Government, Economics & Finance, Health Care, Leftism, Medicine, Politics, Predictions | 7 Comments »

    The Drug War

    Posted by Michael Kennedy on 15th August 2013 (All posts by )

    My sentiments on the whole drug question have been influenced by some experience with the medical aspect of the problem. Drugs are slipping out of any control due to developments in synthetic variations of older substances that stimulate brain chemistry, sometimes in unknown ways. The traditional drugs, if we can use that term, are also slipping out of control with Mexican drug wars replacing the Columbian cartels even more violent than their predecessors.

    What about marijuana ? It is widely used by the younger generation and, while I do think there are some harmful consequences, especially in potential schizophrenics, the fact is that the laws are widely ignored and do little good and much harm. First, what about the link to psychosis ?

    Epidemiological studies suggest that Cannabis use during adolescence confers an increased risk for developing psychotic symptoms later in life. However, despite their interest, the epidemiological data are not conclusive, due to their heterogeneity; thus modeling the adolescent phase in animals is useful for investigating the impact of Cannabis use on deviations of adolescent brain development that might confer a vulnerability to later psychotic disorders. Although scant, preclinical data seem to support the presence of impaired social behaviors, cognitive and sensorimotor gating deficits as well as psychotic-like signs in adult rodents after adolescent cannabinoid exposure, clearly suggesting that this exposure may trigger a complex behavioral phenotype closely resembling a schizophrenia-like disorder. Similar treatments performed at adulthood were not able to produce such phenotype, thus pointing to a vulnerability of the adolescent brain towards cannabinoid exposure.

    This suggests that adult use may be less harmful.

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    Posted in Civil Society, Health Care, Law Enforcement, Libertarianism, Medicine, Political Philosophy, Science | 26 Comments »

    Alternatives to Obamacare

    Posted by Michael Kennedy on 26th July 2013 (All posts by )

    As Obamacare looks more and more as though it will collapse, there are some alternatives beginning to appear. Several years ago, I suggested using the French system as a model. At the time, the French system was funded by payroll deduction, a source affected by high unemployment, and used a national negotiated fee schedule which was optional for doctors and patients. The charges had to be disclosed prior to treatment and the patient had the option of paying more for his/her choice of physician. Privately owned hospitals competed with government hospitals and patient satisfaction was the highest in Europe.

    Recently the French system has run into trouble.

    French taxpayers fund a state health insurer, “Assurance Maladie,” proportionally to their income, and patients get treatment even if they can’t pay for it. France spends 11% of national output on health services, compared with 17% in the U.S., and routinely outranks the U.S. in infant mortality and some other health measures.

    The problem is that Assurance Maladie has been in the red since 1989. This year the annual shortfall is expected to reach €9.4 billion ($13.5 billion), and €15 billion in 2010, or roughly 10% of its budget.

    This may be due to several factors. The French economy is in terrible shape with high unemployment. More of the funding for the health plan is coming from general revenues. This was not how it was supposed to work. It was payroll funded, much as the German system is, with a wider source than individual employers. This allows mobility for employees and allows employers to distribute risk among a larger pool. Germany allows other funding sources such as towns and states. I think it is still a good model for us but, with the passage of Obamacare, it will take a generation before another large reform would be viable. Obamacare must stand or fall first and I think it will fall but, as in most government programs, it takes years before the sponsors will admit defeat.

    Another proposal has been made by a serious study group.

    1. The government should offer every individual the same, uniform, fixed-dollar subsidy, whether used for employer-provided or individual insurance. For everyone with private health insurance, the subsidy would be realized in the form of lower taxes by way of a tax credit. The credit would be refundable, so that it would be available to individuals with no tax liability.

    2. Where would the federal government get the money to fund this proposal?

    We could begin with the $300 billion in tax subsidies the government already “spends” to subsidize private insurance. Add to that the money federal, state and local governments are spending on indigent care. For the remainder, the federal government could make certain tax benefits conditional on proof of insurance. For example, the $1,000 child tax credit could be made conditional on proof of insurance for a child.10 For middle-income families, a portion of the standard deduction could be made conditional on proof of insurance for adults. For lower-income families, part of the Earned Income Tax Credit could be conditioned on obtaining health coverage.

    3. If the individual chose to be uninsured, the unclaimed tax relief would be sent to a safety net agency providing health care to the indigent in the community where the person lives, so that it would be available there in case he generates medical bills he cannot pay from his own resources. The result would be a system under which the uninsured as a group effectively pay for their own care, without any individual or employer mandate. By the very act of turning down the tax credit for health insurance in choosing not to insure, uninsured individuals would pay extra taxes equal to the average amount of the free care given annually to the uninsured. The subsidies for the insurance purchased by the insured would then effectively be funded by the reduction in expected free care the insured would have consumed if uninsured. [See Figures II and III.]

    The paper goes on to explain the proposal The trouble is that this is another major reform and I see no chance for it in the foreseeable future.

    What then is the most likely development ?

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    Posted in Big Government, Economics & Finance, Health Care, Medicine, Politics | 20 Comments »

    The Connecticut Massacre

    Posted by Michael Kennedy on 15th December 2012 (All posts by )

    There is information still coming to light about this awful case. Early reports, such as the name of the shooter and the alleged murder of the father, were predictably wrong. It turns out that the shooter, named Adam Lanza, a 20 year old with a history of odd behavior and some evidence of mental illness, such as autism, was living with his mother who was his first victim. There are a number of suggestive reports, that she decided to “stay home to care for” her 20 year old son.

    The treatment of severe mental illness in this country has been altered for the worse by a movement that began in the 1960s when mental illness began to be described as a “civil rights ” issue. Several books and movies described abuse of power in commitment of the mentally ill. The first such movie was “The Snake Pit” in which a young woman is committed for what sounds like schizophrenia. The treatment of the time (1948) can be seen as barbaric but there was nothing else available. She did recover, although we know that without adequate treatment, recovery from schizophrenia is unlikely.

    The movie that really devastated the mental hospital system was called “One Flew Over the Cuckoo’s Nest” and starred Jack Nicholson.

    The movie was powerful in showing the Nicholson character as a guy who just is “different” and harmless.

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    Posted in Academia, Civil Liberties, Civil Society, Crime and Punishment, Health Care, Privacy, Science | 31 Comments »

    Dick Boggs

    Posted by Michael Kennedy on 16th March 2012 (All posts by )

    When I was a medical school junior, we had a rotation on the Neurology service at LA County Hospital. One of my classmates was planning a career in neurology but the reason it was so popular with the students like me who were interested in surgery was that we got to do tracheostomies. A number of patients with severe neurological lesions would require respirators or had trouble with airway secretions requiring a tracheostomy. This was our one chance to do surgery, even a minor procedure as things go. It was good practice and I later did a lot of tracheostomies, some quite difficult and rushed.

    Our resident was a very interesting guy named Dick Boggs. He was tall and looked a lot like Orson Welles did when he was young and making “The Third Man.” Boggs was quiet and aloof but let us do trachs and work up any patient we wanted to. I had some very interesting cases. One was a woman who showed all the signs of alcoholic neuropathy, which is very similar to diabetic neuropathey. It was a popular rotation for juniors. Boggs was popular among the residents and was elected the president of the Interns’ and Residents’ Association, which under his leadership took on some of the characteristics of a union.

    At the time, intern and resident pay was very low and, aside from a new dormitory that was built for single house staff, we were on our own. I was married with one child, born in March 1965, so I was really on my own. My wife quit her job as a teacher in January 1965 and I was working after hours doing histories and physicals at private hospitals for $7 per hour. Fortunately, my tuition was covered by scholarship but living expenses were tight. We lived on $200/month contributed by our parents, $100 from my father and the same from Irene’s parents. Half of that went for the rent of our two bedroom house in Eagle Rock, near Pasadena. I’m spending some time on details to emphasize what Boggs accomplished for us all.

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    Posted in Academia, Health Care, Human Behavior, Medicine | 6 Comments »

    Does this sound familiar ?

    Posted by Michael Kennedy on 10th September 2011 (All posts by )

    The science community is now closing in on an example of scientific fraud at Duke University. The story sounds awfully familiar.

    ANIL POTTI, Joseph Nevins and their colleagues at Duke University in Durham, North Carolina, garnered widespread attention in 2006. They reported in the New England Journal of Medicine that they could predict the course of a patient’s lung cancer using devices called expression arrays, which log the activity patterns of thousands of genes in a sample of tissue as a colourful picture. A few months later, they wrote in Nature Medicine that they had developed a similar technique which used gene expression in laboratory cultures of cancer cells, known as cell lines, to predict which chemotherapy would be most effective for an individual patient suffering from lung, breast or ovarian cancer.
     
    At the time, this work looked like a tremendous advance for personalised medicine—the idea that understanding the molecular specifics of an individual’s illness will lead to a tailored treatment.

    This would be an incredible step forward in chemotherapy. Sensitivity to anti-tumor drugs is the holy grail of chemotherapy.

    Unbeknown to most people in the field, however, within a few weeks of the publication of the Nature Medicine paper a group of biostatisticians at the MD Anderson Cancer Centre in Houston, led by Keith Baggerly and Kevin Coombes, had begun to find serious flaws in the work.
     
    Dr Baggerly and Dr Coombes had been trying to reproduce Dr Potti’s results at the request of clinical researchers at the Anderson centre who wished to use the new technique. When they first encountered problems, they followed normal procedures by asking Dr Potti, who had been in charge of the day-to-day research, and Dr Nevins, who was Dr Potti’s supervisor, for the raw data on which the published analysis was based—and also for further details about the team’s methods, so that they could try to replicate the original findings.

    The raw data is always the place that any analysis of another’s work must begin.

    Dr Potti and Dr Nevins answered the queries and publicly corrected several errors, but Dr Baggerly and Dr Coombes still found the methods’ predictions were little better than chance. Furthermore, the list of problems they uncovered continued to grow. For example, they saw that in one of their papers Dr Potti and his colleagues had mislabelled the cell lines they used to derive their chemotherapy prediction model, describing those that were sensitive as resistant, and vice versa. This meant that even if the predictive method the team at Duke were describing did work, which Dr Baggerly and Dr Coombes now seriously doubted, patients whose doctors relied on this paper would end up being given a drug they were less likely to benefit from instead of more likely.

    In other words, the raw data was a mess. The results had to be random.

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    Posted in Academia, Bioethics, Environment, Health Care, Science, Statistics | 17 Comments »

    Global Warming and acupuncture

    Posted by Michael Kennedy on 16th June 2011 (All posts by )

    It looks as though the sun is entering a new dormant period, similar to the Maunder Minimum which led to the Little Ice Age.

    This will almost certainly end the global warming hysteria in a few years. The people who continue to cling to this sort of hoax, will be looking for the Next Big Thing. I don’t mean to imply that the earth did not warm over the past century. The Little Ice Age ended about 1850 so a warming trend is expected following such an event. The hoax is the contrived evidence that humans are responsible. I was skeptical about that from the first. The forces involved are too large. If humans affected climate, it probably began with the development of agriculture. Perhaps we have had no ice age in the past 10,000 years because of the effects of agriculture and forest changes. I have previously discussed this and nothing has changed my mind.

    The next question is what will replace global warming as the religion of the bored classes ? There are signs that it may be “New Age” medicine. This sort of thing is common in certain circles and has considerable similarity to the global warming arguments.

    The Center for Integrative Medicine, Berman’s clinic, is focused on alternative medicine, sometimes known as “complementary” or “holistic” medicine. There’s no official list of what alternative medicine actually comprises, but treatments falling under the umbrella typically include acupuncture, homeopathy (the administration of a glass of water supposedly containing the undetectable remnants of various semi-toxic substances), chiropractic, herbal medicine, Reiki (“laying on of hands,” or “energy therapy”), meditation (now often called “mindfulness”), massage, aromatherapy, hypnosis, Ayurveda (a traditional medical practice originating in India), and several other treatments not normally prescribed by mainstream doctors. The term integrative medicine refers to the conjunction of these practices with mainstream medical care.

    Here we have what may become the replacement for AGW in the minds of the exquisite privileged class. It has all the requirements.

    1. America is corrupt and inferior ? Yes. (See the comments)

    2. Capitalism is corrupt and inferior ? Yes

    3. Only the truly intelligent and sensitive can appreciate it ? Well.

    You might think the weight of the clinical evidence would close the case on alternative medicine, at least in the eyes of mainstream physicians and scientists who aren’t in a position to make a buck on it. Yet many extremely well-credentialed scientists and physicians with no skin in the game take issue with the black-and-white view espoused by Salzberg and other critics. And on balance, the medical community seems to be growing more open to alternative medicine’s possibilities, not less.

    That’s in large part because mainstream medicine itself is failing. “Modern medicine was formed around successes in fighting infectious disease,” says Elizabeth Blackburn, a biologist at the University of California at San Francisco and a Nobel laureate. “Infectious agents were the big sources of disease and mortality, up until the last century. We could find out what the agent was in a sick patient and attack the agent medically.” To a large degree, the medical infrastructure we have today was designed with infectious agents in mind. Physician training and practices, hospitals, the pharmaceutical industry, and health insurance all were built around the model of running tests on sick patients to determine which drug or surgical procedure would best deal with some discrete offending agent. The system works very well for that original purpose, against even the most challenging of these agents—as the taming of the AIDS virus attests.

    But medicine’s triumph over infectious disease brought to the fore the so-called chronic, complex diseases—heart disease, cancer, diabetes, Alzheimer’s, and other illnesses without a clear causal agent. Now that we live longer, these typically late-developing diseases have become by far our biggest killers. Heart disease, prostate cancer, breast cancer, diabetes, obesity, and other chronic diseases now account for three-quarters of our health-care spending. “We face an entirely different set of big medical challenges today,” says Blackburn. “But we haven’t rethought the way we fight illness.” That is, the medical establishment still waits for us to develop some sign of one of these illnesses, then seeks to treat us with drugs and surgery.

    No doubt the author would prefer that people died too young for chronic disease to affect them.

    A well-known science blog states the case for scientific medicine.

    Speaking of bad ideas, in contrast to his previous article, in which he managed at least to get the gist of what Ioannidis teaches but merely spun it in what I considered to be an annoying fashion, the entire idea behind Freedman’s new article channels the worst fallacies of apologists for alternative medicine. The whole idea behind the article appears to be that, even if most of alternative medicine is quackery (which it is, by the way), it’s making patients better because its practitioners take the time to talk to patients and doctors do not. In other words, it’s a massive “What’s the harm?” argument. Yes, that’s basically the entire idea of the article boiled down into a couple of sentences. Deepak Chopra couldn’t have said it better. Tacked on to that bad idea is a massive argumentum ad populum that portrays alternative medicine (or, as purveyors of quackademic medicine like to call it, “complementary and alternative medicine” or “integrative medicine”) as the wave of the future, a wave that’s washing over medicine and teaching us cold, reductionistic doctors to care again about patients and thus make them better. Freedman even contrasts this to what he calls the “failure” of scientific medicine. I kid you not. Worse, Freedman makes this argument after having actually interviewed some prominent skeptics, including Steve Salzberg and Steve Novella, in essence, missing the point.

    I expect to see more and more of “alternative medicine” because it appeals to the scientific illiterate and it damns another traditional source of authority, scientific medicine. Global warming hysteria attacks capitalism and prosperity. Alternative medicine is also going to be useful to Obamacare as a way of cutting reimbursement for traditional care. There are assumptions that it is cheaper. It may be cheaper per session, although is also uncertain, but there is no end point to such treatment. Who can say when the treatment is enough if it cannot be measured ? The theory that it is cheaper will be a powerful wind behind it. Watch for more and more about it in the left leaning media.

    Posted in Health Care, Medicine, Science | 27 Comments »

    A Very Modern Christmas

    Posted by onparkstreet on 14th December 2010 (All posts by )

    The hospital is dotted with Christmas trees: plastic green triangles, some tall and some small, in lobbies and resident rooms and offices. The lights twinkle, golden tinsel glitters, and little angels top the trees. And yet, every posted sign or printed document reads, “happy holidays!”. Easier that way, I suppose. Covers the lot.

    Shopping in the neighborhood, I notice that rows of neat little Christmas trees, in shades of pale gray, are standing upright in oblong concrete planters lining the sidewalks. In summer, the planters hold flowers in every color imaginable. Now, in winter, the Christmas season, bright lights are strung around the oddly ethereal trees, shocking pink and blue and purple to contrast with the dove gray branches and silvery bows. From a distance, it looks like an 80s dance floor.

    We will have our annual Christmas potluck lunch at work next Monday and food from every corner of the planet, seemingly, will grace the table. Freshly made hummus and pita, spicy fragrant curries and rice, baba ganoush sprinkled with pomegranate seeds, sesame noodles and eggrolls, home made Filipino Pancit, southern fried chicken, red beans and rice, pierogies, baked ham and chicken and salad and cookies and cakes. Well, that’s some of what we had last year I think. We’ll see about this year. The potluck menu rotates because, in a busy teaching hospital like ours, the staff rotates a lot too. It’s a very nice event and a chance to catch your breath during a busy work day, wish others well and a Merry Christmas, and remember just why it is that you chose to practice medicine. You wanted to help people and you wanted to do it in an environment that is warm and nurturing.

    Posted in Christianity, Diversions, Holidays, Human Behavior, Personal Narrative | 4 Comments »

    Smart Phones and Medicine

    Posted by onparkstreet on 21st November 2010 (All posts by )

    Teledermoscopy enables rapid transmission of dermoscopic images via e-mail or specific web-application and studies have demonstrated a high, 91%, concordance between face-to-face diagnosis and remote diagnosis of such images. Further to this, telediagnosis of melanocytic skin neoplasms achieved a diagnostic accuracy of 83% versus the conventional histopathologic diagnosis. Mobile teledermoscopy is the combination of such approaches enabling transfer of images captured with cellular phones coupled with a pocket dermatoscope and preliminary studies have demonstrated the feasibility and potential of its use in triage of pigmented lesions. Such applications are of benefit to physicians in enabling easy storage of data for follow-up or referral of images for expert second opinion and may facilitate a “person-centered health system” for patients with numerous moles and pigmented skin lesions who could forward images for evaluation.

    Semin Cutan Med Surg. 2009 Sep;28(3):203-5. Mobile teledermoscopy–melanoma diagnosis by one click?

    More data just means more data. Someone – or some thing – has to interpret all of the information generated by new technologies. Too bad we are creating a health care system with all the responsiveness of a snail on downers.

    Model that we are creating: A federal bureaucrat commissions a study, to be vetted by a centralized board, to be further vetted by a state panel, to be implemented by a local health care provider, and zzzzzzzzzzzzzzzzzzzzzzz….

    Model real-life Millenials will someday use for medical diagnostics: “There’s an app for that.”

    I’m exaggerating for effect so don’t get too hung up on the potential accuracy of the prediction. You get the point.

    Yell at me in the comments or whatever.

    Posted in Academia, Medicine | 8 Comments »