Monday, July 30, 2007


I have seen Michael Moore’s SICKO.

It is a truly remarkable work of theatrical advocacy. There are more than a few statements of alleged fact with which one could take exception, but they pale into insignificance compared with the broad sweep of the case he makes. It is movie that everyone ought to see.

Towards the end of the film, Moore summarizes its overall theme by making a statement to the effect that the issue he is posing is whether we will respond to the needs of our fellow Americans as we or me. SICKO is an argument for we.

It might fairly be said that this we/me question was the dominant social and economic issue of the 20th century, with the we side being identified with socialism and the me side with capitalism.

By the end of the century, it seemed that the me side had won out. China and the countries of the defunct Soviet Union, formerly claiming to be champions of the we approach, were converting their economies to private enterprise capitalism. After years of left leaning governments, Great Britain turned to the me philosophy of Margaret Thatcher, much of which was soon adopted by the Labor Party under the leadership of Tony Blair. Similar trends could be seen elsewhere in Europe and in the U.S.

None of that has fazed Michael Moore. An unabashed advocate of we, he was bold enough to include in his film a rather extended interview with Tony Benn, an articulate leftist among leftists in the heyday of socialist rule in the U.K., now an octogenarian who hasn’t been heard from for years.

The we philosophy is morally compelling and has great emotional appeal. Who wants policy to be enforced when a fellow human being is ill or in genuine need? Who wants to defend the right of insurance companies and drug manufacturers to make huge profits from human misfortune?

But the problem with we-ness is finding a way to make it work. Some of the difficulties are included in the film, such as the French worker enjoying a three-month recuperation at full salary on the French Riviera surrounded by buxom beauties and the government-paid home help aide doing laundry for an English single mother. Moore made much of the we philosophy of France, but between his filming of the movie and its showing in the U.S., the French showed their impatience with its excesses by sweeping into office a President promising to move France in the me direction.

There is nothing attractive about a me approach that lacks sensitivity to the needs of others. At the same time, it may be that something in human nature makes pure we-ness impractical.

So maybe, as in so many other cases, the truth lies somewhere in between.

Saturday, July 28, 2007

A Model to be Looked At?

Mark Woodring has referred me to an article in the July 9, 2007 issue of the Los Angeles Times, which includes a report of an interview with Dr. Donald Klitgaard of the Harlan [IA] Clinic.

The 9-physician Harlan Clinic is part of the Myrtue Medical Center (MMC) of which Woodring is CEO and Klitgaard is Chief of Staff. MMC also includes the 40-bed Myrtue Memorial Hospital (MMH). It provides high quality, low cost care to the 13,000 residents of Shelby County, some 5,000 of whom live in Harlan, its county seat.

Harlan is my home town (we still maintain a small home there) and Klitgaard’s father Don and I attended Harlan High School together.

The LA Times article was about picking a doctor. Klitgaard was interviewed because the Harlan Clinic is one of 36 family practices participating in a performance study being sponsored by the American Academy of Family Practice. The study is scheduled to run through 2008.

I have watched MMC develop over the years under the uncommonly capable leadership of Woodring and his predecessor Steve Goeser. It is a single corporation that employs the physicians of Harlan Clinic as well as the staff of MMH. It is of manageable size with low overhead and impressive operational flexibility. It refers patients in need of specialty care to larger facilities in Omaha, Nebraska, some 50 miles away, from which a number of specialists travel to MMC to hold clinics on a regular and scheduled basis.

It seems to me that MMC offers a model that ought to be looked at as part of the health system of the future. Now that protocols and quality reporting are relatively well established, clinical performance could be readily monitored. I see no reason why the model could not function in urban as well as rural areas. It could be a sort of McDonald’s of health care, offering basic health services safely, at a high level of quality, and at reasonable cost.

In the past, all the glamour in health care has gone to the big urban teaching hospitals and little attention has been paid to institutions like MMC.

Maybe that ought to change.

Wednesday, July 25, 2007

More on Health Care Spending

Long-time personal friend and periodic blog contributor Bill Busby has the below to say about our high level of spending for health care (Virginia is his deceased wife):

May I add my two cents worth concerning the relatively high cost of medical care in the USA as opposed to other countries? (These are in addition to those suggested by others.)

1. We have a very efficient medical bureaucracy and the primary function of any bureaucracy is to protect itself and to grow. Instead of an individual doctor with a nurse and, maybe, an office girl, we have a group of doctors with technicians, nursing assistants, assistant nurses, insurance specialists, etc., etc. Every one of these people expects to be paid and the only way to pay them is to get more patients. Thus, we pay much more (in 1950 dollars) for a 15 minute, every 3 month appointment with a doctor than we used to for an occasional visit when something was wrong.

Of course, I have to admit that many of these new "professions" have come into being with the mad rush of 20th and 21st century technology.

2. Doctors have wrapped themselves in the robes of deity: to, heaven forbid, question a DOCTOR is on the same plane as denying the divinity of Christ. (A few months ago, I met a former family physician in a store. When he asked about Virginia, I told him she'd died five years ago of a disease he told us didn't exist--post polio syndrome. The look on his face was priceless. Finally he had to agree that, sometimes, even THE DOCTOR can be wrong.)

3 Mark Twain in his book "Letters from the Earth" had it right. Despite the promises of a better life to follow, most of us, even the most ardent Christians, want to hang on to this one as long as possible. We'll take any advice and pay any price to avoid "going on to the great beyond." In other words, we push the health care system to find a cure for all of our afflictions, even old age. The Islamics seem to be the only religionists who truly believe in a better world beyond this one. They're willing to blow themselves up for the promise of 70 virgins in heaven.

Thursday, July 12, 2007

How We Came to Spend so Much

In his response to my recent posting about the central dilemma of health care reform, John Kelly asked if I had some thoughts on how the USA came to spend so much on health care. He quoted a Chicago Tribune interview that blamed commercialization.

I attribute the high level of expenditure to a combination of factors. They are

(a) Our ability to afford it, thanks to a large and growing economy.
(b) The high position occupied by health care in our society’s hierarchy of values.
(c) A lack of recognition that an important social service could be overfunded. It had never happened before.
(d) A perception of health care as a ministry not to be profaned by the vulgarity of market competition.
(e) An “onward and upward” culture that considered growth to be a virtue.
(f) A health care system led by imaginative, energetic, and ambitious people able to find justifiable ways to spend money faster than the additional income needed to support them could be generated.
(g) A pluralistic system of financing that allowed the health care system to tap into multiple sources of money.

In the years following World War II, the United States was the only country with a private economy strong enough to support health care at a socially acceptable level. Health insurance played an important role in that monthly prepayment was a way to get the well to pay for the care of the sick. Before insurance, charity and the sick themselves were the only sources of revenue.

By the early 1960’s it became apparent that private health insurance was not going to work for the elderly or the poor. So we got the Social Security Amendments of 1965 which created Medicare and Medicaid.

With the enactment of those programs, the health care system had access to revenue from government (mainly federal), from private corporations (tax deductible health care benefits), from tax deductible private donations, and from individuals; i.e., from every important segment of the economy.

So there was a fertile field in which the mutually reinforcing factors listed above could operate and, as they say, the rest is history.

Wednesday, July 11, 2007

Mugglie on Health Care Costs

Social Worker and periodic commenter Cindy Mugglie has this to say about commercialism and the cost of health care:

The commercialism of health care must have something to do with rising costs. Just the other day I heard of a study that found people who see television ads about medications are more likely to get prescriptions for those meds than are people who do not see the television ads. So there you have people making extra trips to the doctor and taking more medications, things that might not happen but for television ads.

About 5 years ago I got a card in the mail telling me that some state of the art diagnostic testing facility on wheels would be in my area. It went into detail about the various healthcare tests that everyone should have and how I should not miss the opportunity, as they would be in the area for a very short time. I didn't pay much attention until my elderly clients started saying they had received the same cards and asking if I thought this was important (I was a social worker in senior housing at the time). Should they have these tests? I directed them to ask their doctors, and they all reported back; their doctors had told them these were all unnecessary tests that would only be done if they had symptoms indicating a need, and to top it all off, the tests were not covered by any kind of insurance if not ordered by a doctor. Hands down the doctors said it was a rip off! I reported the situation to the state attorney general but I can't recall the outcome. I've always wondered how many people were convinced to throw hundreds of dollars into having those tests.

I also wonder, could health care costs be rising due to technology? Are the machines and equipment used for health care improved and updated so often that there is a need to buy newer and better models every few years, and if so, are the newer models really all that much better or is the newer and better label just a way to sell more products?
Still More on Ministry versus Business

Long time friend and colleague Jim Staton had the following to say about Cindy Mugglie’s comments on the subject:

The response by Cindy Mugglie raises the old dilemma that the public is not able to judge the competence of either professionals or institutions, especially in cases when it is "professionals" who set up and run an institution. Once we get outside of teaching hospitals and some good community hospitals I do not believe the general public is able to know whether or not a hospital is adequately supervising its physicians.

Tuesday, July 10, 2007

More on the Central Dilemma

Fellow alum and blogger (www.grindstonehc.blogspot.com) John Kelly had the following to say in response to the posting titled The Central Dilemma of Health Care Reform:

You’ve gotten most of the ‘central dilemma’ spot on. We (USA) spend too much on healthcare. Yet, in a free society, isn’t it our right/choice to spend as much as we wish? Years ago, (about 17 years give or take) my guess was that we would freely choose to spend 25% of GDP on healthcare. Within a few short years, we’ll be very close to that. At that point, we face a choice…simple really…spend more or watch the economy collapse.

Relman states (in a recent Chicago Tribune interview) that we do spend way too much on healthcare (so you’re in good company) and fingers the culprit as the commercialization of healthcare services (all aspects from insurance to provision). This is big money business. Even bigger than the Military-Industrial complex that Dwight D. Eisenhower warned against in his farewell address.

Any thought on the commercialization as root cause?

I do have some thoughts, which I’ll put in a separate posting.

Monday, July 09, 2007

Smart cards, DVDs, CDs, etc.

Responding to a recent posting, Pat Keith of Ocala, Florida reports as follows:

I was most interested to read in your last posting of the reference to "smart cards" which hold patient information. I relate the recent use of a similar tool:

Our retired pastor was visiting friends and family in NY when he experienced changes in his vision. After some extensive testing in a hospital on Long Island (Stony Brook area, I believe), it was determined that he was having a recurrence of cancer in the form of brain tumors. All of his testing results, reports, X-rays and MRIs were included on a DVD and/or CD and prevented the repeat of testing in FL, allowing his radiation treatments to begin the day after he flew home. High marks to that Long Island hospital!

Pat is a retired school teacher and administrator. We share two grandsons.

Saturday, July 07, 2007

The Central Dilemma of Health Care Reform

The central dilemma of health care reform is this:

(a) the crisis arises from spending too much on health care.
(b) all of the political proposals for reform call for spending even more.

The usual rhetoric relating to the crisis in health care does not talk about expenditures, referring instead to high costs. But the only way to incur a cost is to spend money. So if costs are too high, then it follows that expenditures are too high.

Friend and erstwhile fellow Detroit parishioner Chuck Kleber was good enough to forward to me an article from the July 6 issue of The New York Times summarizing the positions of the various presidential candidates for the overhaul of the health care system.

The article suggests that the health care issue has to do mainly with the cost of care. However, most of the proposals being bruited about have to do with providing coverage for the uninsured. All of them in one way or another would increase spending and, therefore, cost. The only references to cost reduction were a proposal by Senator Hillary Clinton for a “Best Practices Institute” and the mention of reliance by both parties on better health information technology and disease management – neither of which, by itself, has to date shown much promise for cost reduction.

Everyone seems to have a pet explanation for the failure of the Clinton health care reform proposals of 1993-94. My own is that when push came to shove, there was no willingness to pay for them. The idea of pouring more money into an already overfunded system couldn’t be made to fly.

I suspect that continues to be the case and that the issue of health care reform will be with us for some time yet.

Monday, July 02, 2007

CEO Awards

Health care executives are under a great deal of pressure these days to make more use of computers; i.e., information technology, or IT. That creates the risk that IT will be implemented mainly for its own sake rather than for the purpose of improving the performance of the health care provider system.

In its June 25, 2007 issue, the Modern Healthcare magazine announced its 2007 CEO IT Achievement Awards, which it bestowed in cooperation with the Healthcare Information and Management Systems Society.

In a companion article, David Burda, editor of the magazine, invited comments. I accepted his invitation and sent him the following e-mail:

“The report of the 5th Annual CEO IT Achievement Awards was interesting but would have been even more so had it indicated what had been achieved through the use of IT.

For example:

Alan Aviles of New York City Health and Hospitals gets credit for “smart cards” that can accommodate an individual’s medical records, including primary diagnoses, laboratory results and even an electrocardiogram. One wonders to what extent they are proving useful and what the impact has been on cost and quality.

John Ferguson of Hackensack (N.J.) University Medical Center is recognized for implementing “Mr. Rounders;” robots that let doctors interface with their patients from remote locations. The award citation does not report any statistics that indicate benefits realized.

Michael Murphy of Sharp HealthCare in San Diego is complimented for his support of “a difficult decision to deploy a single-product, inpatient electronic medical record.” Previously, different programs had been used for different applications and it turned out they couldn’t be made compatible with each other. As a result, nurses “had to toggle between the systems.” Surely there were some benefits from the expensive redo other than relieving nurses of that inconvenience. If so, the citation doesn’t mention them or indicate whether they were realized.

IT will pay off through the implementation of new and better ways of providing care that would not be possible without it. Short of that, the main result will be to add cost. It is tempting to conclude that this is what has happened under the leadership of your awardees.”

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