Archive for category Politics

Tiers of U.S. Healthcare

A recent U.S. presidential-candidate debate included proposals on Medicare-for-all, care for illegal immigrants and private insurance: supposedly a three tier system. Exactly which existing tiers would be removed, which would be funded and how would the budget for care work?

Consider the layer cake of U.S. healthcare, as it exists. Start at the top where little figures of a bride and groom might stand. That is the highly-privileged care provided to members of Congress and many government employees (“Cadillac” health plans with a large percent government subsidized plus pre-tax perks). That insurance provides good care (not as good as the care in the French system, but pretty good).

The next tier is the “CEO” or “rich guy” healthcare. They have so much money they don’t need insurance. They just buy what they want at big name hospitals with private suites staffed by nicely dressed doctors in suits and young nurses with little pointed hats. The motto is “whatever you want”. CT scans of everything happen at least once a year and heart tests proceed just because “you can’t be too careful”. And, heavens, the food you like is on your diet. Rating of care: poor.

The next tier is a hodgepodge of layers or “options” offered by many insurance companies like Blue Cross, UnitedHealthcare, Aetna etc. These are mostly provided through an employer group plan. And, sometimes purchased individually at a higher cost if the person is part-time or retired before age 65. Some plans have high deductibles and high co-pays that financially make care difficult to obtain. Some closed panels of providers limit where a person can obtain care and limit the options for moving or travel. The insurance companies scrape off 15% of the icing (administrative fees). Rating of care: fair to good.

Next is the Medicare tier divided into several layers including Medicare with a supplement (fee-for-service) and Medicare Advantage (per-capita). Rating of care is good with a plus for lower cost compared to the higher layers. Unfortunately, Medicare does not negotiate drug prices according to laws supported by drug companies. Rating of care: good.

Next are decorations of socialized medicine. These include the Veterans Administration, Indian Health Service and various levels of military healthcare (Tricare). Rating of care: good.

Next is Medicaid. A State run and federally supported insurance for the poor. It is limited by budgets and willing providers. Rating of care: fair if you qualify, but many who need care don’t qualify for a variety of reasons.

Finally, the bottom layer. The layer for those with no insurance and no funds. All States require emergency rooms to provide care to “stabilize” a mental or physical illness. Anyone can obtain health care in the U.S. based on this nearly insane model where people wait until they are really sick to receive care in the most expensive setting. The bills, which none in this layer can pay, are astronomical and serve only to further bankrupt the unfortunate. Rating of care: poor with no connection to a primary care provider or mental health follow-up.

In conclusion, the recent superficial debate about healthcare seems to hinge on hot-button issues like rich insurance companies, greedy drug companies and desperate immigrants who become sick. Of course healthcare costs money — only a politician would say otherwise. The healthcare system we have or will have is exactly what we plan.

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Leadership and Narcissistic Personality Disorder

ilovemeThe label narcissist or description as narcissistic has appeared in the current presidential campaign rhetoric.  Dictionary.com defines narcissism:

Inordinate fascination with oneself; excessive self-love; vanity.  Synonyms: self-centeredness, smugness, egocentrism. 

Personality is the way a person views themselves and the way they emotionally interact with the world.  We all have a personality.  The first writings about personality were in the Renaissance.  In modern times psychologists have applied scientific methods to this difficult concept.

Psychologists have discovered some very important things about personality.

  1. Personality is persistent through adult life and is likely coded in our DNA.  Even animals have personality.
  2. The survival of a tribe may be enhanced by having members with different personalities.  Like members with confidence in themselves, members who are passive followers, or members who like consistency.
  3. People can have bits and pieces of different personalities which are called personality traits.
  4. Personality alone does not define a person psychologically.  Other things like intelligence, environment and interactions with other people have a huge impact.
  5. A little personality is very good.  But, a lot of a personality which is rigid and unyielding to social pressures is actually a disease.  The disease is called a “personality disorder” rather than a “personality trait”.
  6. Personality disorders cause problems for the person who has them.  They ruin relationships, cause financial harm, and may cause unfavorable interactions with the law.
  7. Finally, a person is generally blind to their own personality and can not change it.  People can learn coping mechanisms by appreciating how other people react to them — sometimes called mirroring.  An overbearing person might “tone it down” in order to make friends.

So, back to the narcissistic personality disorder.  The scientific definition can be found in the Diagnostic and Statistical Manual (DSM).  The DSM is a publication of the American Psychiatric Association that seeks to define mental disorders for the mental health professions.  Click here for a link to the part about personality disorders.

Key elements include:

  1. A high degree of self-esteem.  “I am great and only I can do things well.”
  2. Validating self worth through others.  “Everybody likes me and knows I am great.”  They tend to be surrounded by people who do think they are great or perhaps are unwilling to challenge that assumption.  Extreme dislike of people who don’t appreciate their self-perceived greatness.
  3. Setting high standards to gain approval of others.  “I follow tax rules so well it makes me a success.”
  4. Lack of empathy.  Actions they take are viewed on how they affect them rather than the harm, embarrassment, or financial ruin that others may experience from the interaction.  Divorce and bankruptcy are sometimes the result.
  5. Difficulty with intimacy.  Relationships are superficial — glad handshakes or kisses that have no underlying meaning.
  6. Shows arrogant, haughty behaviors or attitudes.  Such as denigrating minorities or the opposite sex.  And, strongly seeks the attention of others.

OK, this could describe many politicians!

But, is this the personality most modern people want in a leader?  Probably not.  We don’t need a leader to take us on a hunt for a woolly mammoth.  In primitive times people needed a grandiose leader to spur them on, but it’s likely when the mammoth stepped the leader the feeling was “better him than me.”  Now we want “servant leaders”.  People who have personality traits adapted to successfully improve our lives, not just theirs.

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VA appointment problems — same everywhere

vaphoenixAccording to “The Fix” blog by the Washington Post the VA has problems making timely appointments for patients to see a care provider.  The issue “hit the fan” when it was reported veterans died while waiting for appointments.   So, can an effort to provide quality care exist in an environment where funds are limited?

The first rule of quality management is  the outcome that a process or system delivers is exactly what it was designed to deliver (this is only obvious in retrospect).  The second rule is to change the process rather than blame the people involved if the outcome is not what is wanted.  The third rule is to change the process when needed.  The fourth rule is to be fair and allocate resources according to need.

The VA has a huge job.  But, it is often congratulated for delivering very good care at a price less than standard insurance based care for similar diseases.  Before firing the managers of the VA ask what the waiting time is for appointments at your local psychiatry office or local internist?  And, how many people die while waiting for those appointments  — lots.

Like it or not the VA is socialized medicine.  The congress sets the budget and sets the benefits veterans may receive.  The VA is not an open system, it has cost constraints.  For the US Congress to suggest otherwise is disingenuous (a lie).  The truth is Congress must manage the VA, must set the budget, must monitor cost, must decide what benefits to offer, must limit the medications to be used, must bargain for good medication prices and must provide access on a timely basis — to be fair.

Short waiting time for a needed appointment is a quality goal.  Monitoring the goal and correcting the process to meet the goal is essential.  The process needs tweaking frequently.  If the active military doctor says the discharged veteran needs to be seen within 2 weeks then make it so!  If other services with less impact on care need to be cut back then make it so!  Initial evaluation is very important because without evaluation the need for care can not be known and the fairness to deliver care to the ones most in need is lost.

Anticipating the need for care is also essential.  VA care is part of the cost of war.  300,000 soldiers suffered traumatic brain injury in the Afghanistan and Iraq wars.  It does not take a brain surgeon to realize the VA will need funds and staff to meet the care obligation.  If we need to train more doctors, nurses, PA’s and nurse practitioners then make it so!  Training takes many years which needs to be anticipated by Congress.  If the boat has a leak don’t wait until it is about to sink before doing something.

Back to the basics.  The very notion the VA problems should or could be fixed by firing someone is counterproductive and uninformed.  Should the process of evaluating recently discharged veterans be changed? — absolutely.   Throwing more money at a problem without changing the system is doomed to failure.  Punishing people is not the answer.  What the VA needs is quality management with guts!  The VA can and does deliver good care with appropriately limited resources.

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Addendum (5/30/14)  General Shinseki tendered his resignation today and his second in command (on the job for 3 months) will take over.  One would hope the chaos that it causes will be temporary until a more experienced manager takes over (time will tell).  So what should be done?  The VA needs a manager familiar with quality care who also knows how to manage health care within a budget (that may require someone from outside the country!)  A few realistic things that could be done:

1.  Commission a lean engineering study to make binding recommendations for improved efficiency.

2.  Put the VA care statistics on-line.  Make the VA care  transparent.

3.  Get rid of financial incentives for people who have no control of the process that needs to be changed.

4.  Award innovation.  Awarding “employee of the month” to the person who just got to work on time is not innovation!

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Another thought (6/11/14):  the VA should participate in Medicare Hospital Compare.  Obviously they do not require Medicare but they could submit the same data as other hospitals in the name of transparent care.  The current criticism centers on outpatient wait-times.  It might be interesting to know what wait times might be for other outpatient care clinics like Kaiser Permanente or other vertically integrated systems.

 

 

 

 

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Legal Loopholes — patient bankruptcy

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Again, Steven Brill of Time Magazine twists the knife in the hospital chargemaster with his article “Bungling the Easy Stuff” published 12/16/13.   Uninsured patients continue to suffer hospital price gouging and personal bankruptcy  even though legislative relief was passed years ago when the Affordable Care Act was enacted.

Mr. Brill explains that the ACA prevents hospitals from collecting fees based on the chargemaster (the discredited fee schedule of astronomic charges).  But, because no rules were published in the Federal Register no legal help is available to victims of the practice.

How could this happen?  Because the work to implement the rules to prevent overcharging did not seem worth the effort, after all, in 2014 everybody will have insurance!  Sadly, during the 4 years up to the time when everybody supposedly will have insurance legal enforcement was sidelined.

Although Mr. Brill piles blame on the Obama administration one must also blame those in congress who pass bill after bill to try to stop the ACA — this is unbelievable — one side not implementing the law and the other side trying to kill the law both without regard to the finances of the vulnerable uninsured while hospitals ignore the will of congress and continue an unethical practice.

Mr. Brill has been hammering on the problems of the chargemaster.  It’s time to listen and help your fellow citizens — hospital boards need to stop the practice immediately.  Citizens need to ask hospital board members why they stand for such a cruel and unethical practice?  Perhaps they should give the money back.  However, the current plan is to use the money to buy ads to extol the caring nature of hospitals — that will make us all feel better.

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Affordable Care Act — the right to health care

boxersPresident Obama vs. Republican Congress.  Another grudge match, the sweaty pugilists in the corners, puffs of smoke from the cigars in the front row, the referee  holding the mike, saying  it’s the 8th round, the clang of the bell, the jabs, the left hook, bam – a hard right to the teeth, finally the round ends with a flurry of punches under the belt.  We now interrupt the show for an important announcement.

HEALTH CARE IS NOT A CONTEST.  We are not in a reality show, this is real life.   The consequences are life and death.  Why is there an argument or a fight?

The sky-box view.  Look down at the basic arguments of the two sides:

  • Obama — health care is a right
  • Republican congress — health care is not a right
  • Both agree — health care costs too much

The punches and counter punches.

Punch:  The southern US has poor health care
Counter:  Not our problem, don’t fix it with our money

Punch:  Insurance companies are unethical
Counter:  They are just businesses trying to make a profit

Punch:  Primary care is better and more efficient
Counter:  The market determines what is better or more efficient

Punch:  Everybody should have access to health care
Counter:  Only those who have money should have access

Punch:  If everybody has insurance the system would be more fair
Counter:  Don’t tell me to buy insurance, I will do what I want.

Punch:  Raise taxes to pay for the uninsured
Counter:  We can’t afford higher taxes

Punch:  We already pay enough to provide good health care for everybody
Counter:  We don’t want regulations.  Some of us get great health care already

Punch:  U.S. health care only ranks 30th in the world
Counter:  Poverty and old age are the fault of individuals, don’t count them

Punch:  We need government oversight of health care quality
Counter:  That’s what lawyers are for

Punch: Women need care for female health problems
Counter:  What is good enough for men is good enough for women

Punch:  The constitution gives the right to life, liberty and the pursuit of happiness.  You can’t have any of those things  without being healthy.
Counter:  The Constitution says nothing about a right to health care.

Punch:  All this fighting makes me forget about poor health care quality and high cost
Counter:  Me too.

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