Posts Tagged health-care

Healthcare For Illegal Immigrants — necessary

prohibidoLouise Radnofsky of the Wall Street Journal published her story (3/24/16) about illegal immigrants with the observation they do obtain healthcare (at a low level) in the United States.   As with any good reporter she just reported the facts.  But, what is missing is WHY illegal immigrants receive medical care in the United States.  Clearly illegal immigrants are illegal and they don’t have insurance or money to pay for healthcare.  So why?

The simple answer is because healthcare providers on the front lines believe all lives are worth saving.  And, they will refuse to kill people by withholding care just because society says they should.  If society is so stupid to hire aliens, to pay aliens, to house aliens, to feed aliens, and not have a guest worker program then the healthcare system unequivocally refuses to be “the wall” — ask any doctor who sees a 19 year old with an appendicitis — they will fix the problem and ask questions later.

Here is an actual case:  18 year old Manuel (not his real name) is brought by ambulance to the emergency room after a fall and is barely breathing.  He is placed on life support then the ER doctors ask the on-call doctors in the intensive care unit to admit him.  No questions are asked, he is admitted.

The background later became clear.  Manuel’s father was killed in Mexico by a drug cartel leaving his widow and several children.  Manuel could not find work in Mexico so he crossed the border to find work to support his mother and his siblings.

He was hired by a contractor to build bleachers for a local school football field.  When Manuel fell off the bleachers and hit his head it was the contractor who called the ambulance.  There was no money to pay the hospital bill which was over $100,000 — all the services were a loss to the hospital and doctors.  And yes, this case and many others like it are passed on to the public and insurance companies through higher rates.  That’s how our healthcare system works — like it or not.  It’s been that way for decades.

The ACA with the push for universal insurance makes this under-the-radar care more obvious.  The ACA prohibits payment for illegals.  However, as many large counties in the US have found it is less expensive to provide healthcare, especially for pregnant women, rather than emergency care.  One case of cerebral palsy due to complications of pregnancy can cost millions of dollars.

Manual’s case includes some disturbing facts:  drug abusers in the US are the reason drug cartels exist and in this case were the root cause of Manual’s need to work.  A contractor to a government entity (the county school district) hired Manual and did not provide insurance or workers compensation.

The school district took the lowest bidder for the bleachers and did not specify the workers should have workman’s compensation insurance.  The school district should be responsible for the medical bills but they could not afford the medical bills — the hospital did not try to bankrupt the school with suits.  There was talk of sending Manual back to Mexico by air ambulance, but the health care system in Mexico could not provide high level care.  Absolutely nobody wanted Manual removed from life support because he was an illegal alien — if they did, they would be an accessory to murder.

So, the bottom line, the healthcare system is not ever going to be an accessory to harming people.  Be thankful.  If your son can’t find his insurance card and goes to the ER with an appendicitis he will get care — they will not tell him to go to the parking lot and just die.


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Health Care Lobbying — it’s not for quality


Health care lobbyists are not your friends.  They do not promote quality health care, instead they promote health care business profits.  If only hundreds of millions of dollars could be spent on lobbying for health care quality, on health care access, and on lowering health care cost then the US might not be last in the quality ranking for industrialized countries.  The data below are from the Center for Responsive Politics.  The table shows the amount of money spent for lobbying in 2015 for various industries.   Any wonder why we don’t see much change?

Industry Total (millions) X = 10 million $
Pharmaceuticals &
Health Products
Insurance $118 XXXXXXXXXXX
Oil & Gas $97 XXXXXXXXX
Business Associations $96 XXXXXXXXX
Electronics Mfg &
Electric Utilities $88 XXXXXXXX
Misc Manufacturing &
Health Professionals $73 XXXXXXX
Securities &
Hospitals &
Nursing Homes
Telecom Services $64 XXXXXX
Air Transport $60 XXXXXX
Education $56 XXXXX
Defense Aerospace $56 XXXXX
Health Services &
Real Estate $52 XXXXX
Civil Servants &
Public Officials
Commercial Banks $46 XXXX
TV/Movies/Music $45 XXXX
Automotive $43 XXXX

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Medical Care and Control Theory

sweatshopPiecework maximizes human productivity.  Make more things, get more money.  Garment workers and physicians both have been paid under this system — it’s great if the payment per piece is high but miserable if the price is low.  Because piecework itself is no guarantee of quality inspectors were invented to reject low quality products.  Thus, the little piece of paper in your new shirt pocket “Inspector 23”.

What if you went to a doctor’s office and had to be inspected before the doctor was paid?  You had to have that little piece of paper “Inspector 23” to submit an insurance claim. That’s never going to happen but you get the idea.   The doctor is paid by the number of services but the service should meet a quality standard.

This example is just the tip of the iceberg.  Medicine is discovering process control without much input from the well established engineering field of process control.  It’s sad, and perhaps a little arrogant on the part of medical administrators and law makers, to ignore the extensive work on process control.  People do not like to be considered as little boxes in a system diagram — understandable — but a failure to think in this way is wasting trillions of dollars.  The time for change has arrived.

PieceworkThe black box of medical care is what happens with the doctor-patient interaction.  1) A patient enters the office, operating room or x-ray office then health care happens then 2) the patient leaves.  As it stands now the physician is paid by the number of services performed so the possible process control at points 1 and 2 are wide open.  Nothing is measured, nothing is controlled, and quality is not guaranteed.

Control Theory

Now, consider modern process control with 5 control points, a measurement point and feedback to control the input to the black box of health care.  What is in the black box?  Perhaps just one health care provider.  Or perhaps many health care providers. Instead of a black box it might be a grey box with lots of individual elements.

Parallel SystemPerhaps the box contains whole specialties or perhaps many hospitals within an accountable care organization across many states.

At the highest level of abstraction the feedback loop is intended to minimize cost but at the lowest level the feedback loop is intended to maximize quality.  To make sure throughput is maintained the providers need to be paid by the number of services performed but the flow of patients is choked off if quality is not adequate.

This is rocket science.  But, as Einstein says, a system “should only be as complex as needed”.  Health care is very complicated and at the present the garment industry is not the model the world should be using.  Simplistic ideas of supply and demand are not adequate to make a rocket fly nor to control cost in a health care system.

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High Medical Cost in Winter Havens — unnecessary testing


Snowbirds:  watch out for high medical costs in Florida, Texas, Arizona and California.  According to Elisabeth Rosenthal in the New York Times 2/1/15 “Patients Find Winter Havens Push Costs Up”.  She points out providers in Florida are the worst offenders — the same place notorious for Medicare fraud!

Ms. Rosenthal highlights one patient from New York wintering in Florida who had a checkup for his pacemaker but did not have any new symptoms.  Many in-office tests were ordered by the substitute cardiologist — tests the patient’s regular cardiologist said were unnecessary.

To be very blunt:  cardiologists, and other providers, who order in-office tests make a lot of money from those tests.  Many studies show providers who profit from tests do more tests than providers who don’t profit from tests.  A medical license is not a license to take advantage of patients or Medicare — profit motivation seems to blind some providers to this distinction.

The lure of profit is made greater by a patient not having any new symptoms, not having any record of previous tests, and not having plans for follow-up visits.  It is like the patient has a sticker pinned on their back:  “TEST ME”.   The choice for the cardiologist is simple: either pay the nurse to spend time getting out-of-town records OR make money by repeating tests.  Make money, right!


  • If you are on vacation and have a sudden health problem your best bet is an urgent care center.  They can send you to a specialist, if needed.
  • If you have health problems and will be spending several weeks or months away from home:
    • Talk to you primary care provider:  they may want you to call in and give a report on the phone (diabetes is a good example).  If so, no office visit may be needed while away.
    • Get enough medication to last the trip.  Or, get prescriptions with refills at WalMart or Target and have the prescription transferred to a store near your winter location.
  • Identify a doctor to see in your vacation area before you leave.  Ask friends or other people who winter in the area for a recommendation.  Call the distant provider office and get a FAX number so records can be sent.
  • If your primary care provider thinks you need a health care visit while you are away then make an appointment and have your records sent before you leave home — also take a paper copy!
  • If tests or surgery are recommended then call your regular doctor’s office to see if they agree.
  • Give any provider you see your regular provider’s name, address, phone number and FAX number (a business card is good).  Request that results of visits, tests or hospitalizations be faxed or sent to them — and make sure it happens.  Fill out a release of information form while you are at the office or other facility.

Bon Voyage!

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I’m Sorry — difficult for doctors

sorrybearSaying “sorry” is the human thing to do.  Doctors and nurses should say it when they feel it.

Saying “sorry” seems to have two meanings:  1) something bad happened and I understand your emotions  2) something bad happened and I had some connection with the event for which I feel partly responsible.  Bad things do happen in health care but “sorry” is a very uncommon utterance for health care providers.

Dr. Abigail Zuger writing in the New York Times 7/14/14 “Saying Sorry, but for What?” compared how she felt about a plumber who broke a valve in her house with medical personnel who broke other things —  neither said “sorry.”  Sorry truly does not fix anything;  but, the absence of “sorry” is infuriating.

The problem is ego.  Ego infuses some health care providers with the notion bad things are an act of God but good things are an act of ME.   Absence of “sorry” is a sure sign of defense (a defense of self).  Perhaps the health care provider was spanked as a child or yelled at by teachers.  Who knows … ego has gone wild.

Quality health care depends on people believing errors are due to system failures.  When providers fail to embrace that philosophy they fail to correct problems.  No failure, no correction.

A fall in the hospital can be deadly.  Recently, a family member fell in a room while no nurse was present and they died.  The nurse did not say “sorry.”  There was no acknowledgement of responsibility.   No acknowledgement the system was at fault, no realization there was a better way, and no reason to prevent future deaths.  The simple statement “sorry, I wish I had been there to stop the fall, we will investigate this to help others” would be the right thing to say, and believe.

Lawyers are not the cause of excessive health care ego.  However, lawyers with the threat of suit are a convenient excuse.  When bad things happen honesty and caring are much more likely to assuage the displeasure of a family than stonewalling.


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Waiting for Care — getting worse in the U.S.

longlineElisabeth Rosenthal’s article in the New York Times 7/5/14 “The Health Care Waiting Game” again puts the spotlight on US health care.  This time she points out a problem everybody has been experiencing:  long waits for health care appointments.  The average wait for a family practice appointment is about 20 days with extremes across the country from 5 days in Dallas to 66 days in Boston.  Examination of the private sector begins to make the VA look better.  The question now:  how many people have died waiting for appointments?  (it’s a no brainer — lots)

While wait times in the US have gotten longer they have gotten shorter in other places in the world like the UK.   To some degree the acute problem is an influx of newly insured people into the US market.  But, long before the acute problem there has been a chronic decline.

From an economic point of view it’s all supply and demand (see “Principles of Health Economics) .  Economists point out that the demand for healthcare is almost infinite whereas the supply is always going to be limited.   At some point a line must be drawn.  Is $100,000 per year for a medication acceptable?  Is $500 for a “wellness”exam too much?  Do we really need MDs to treat diaper rash?

Long waiting lines are a sign of poor management.  If a person can’t be evaluated by the healthcare system there is no way to know what is being overlooked.   Perhaps that person in the line only needs a cheap generic medication; not everyone is waiting for hip replacement surgery.  As a country we need to get the best bang for the buck and use limited resources wisely.

We seem to be wasting time coming to grips with healthcare problems.

“I wasted time, and now doth time waste me.”
― William Shakespeare

So, what can a patient do?

  • accept appointments with providers that are farther away
  • accept PAs and Nurse Practitoners for follow-up and simple problems
  • do your part to learn about your health problems so you don’t drag the system down with poor healthcare literacy
  • complain about high prices and long waits and vote for better health care regulation, not less.


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Concierge Medicine — spending your deductable

tank americaine 61k


Jen Wieczner published her article “The Pros and Cons of Concierge Medicine” in the Wall Street Journal  on November 11, 2013.   Concierge medicine doctors are “on retainer” much like some lawyers.  They made a certain reputation as doctors for the rich and famous charging $500 dollars a visit on top of a $30,000 per month retainer.  The above Cartier watch ($61,000) was just what they needed to take the patient’s pulse.

Ms. Wieczner now informs us the conciergierie has found a new way to tap into wealth, a patient’s insurance deductible.   As it turns out, there are a lot more people trying to be frugal with their health care costs than trying to be extravagant.  Those frugal masses are trying to avoid the high out-of-pocket costs for medical exams and tests .  In essence, the profitable concierge doctor finds a way to provide less expensive, but very personal care for cash (not insurance) in the environment below the deductible level found in that silver insurance plan.   And, as P.T. Barnum said, “there’s a sucker born every minute“.

If it were true concierge medicine has some medical skill not provided by most primary care doctors it would be a wonderful development.  But, according the article the wonderful services include PSA testing (not needed), routine blood tests (not advised), testosterone tests (leading to unnecessary and dangerous treatment),  x-rays (never an advised screening), PAP smears (really only needed every 3 years), CAT scans (lots of false positives that require more testing), and MRI scans of the brain (for no known reason except the irrational fear of dementia).  The claim they can do a colonoscopy for $400 dollars is probably true, the same price as in Europe — perhaps mainstream medicine should take note.

The Wall Street Journal is a forum for capitalist ideas.  The notion there is profit to be made in this high deductible world is likely true.   Competition to provide low cost care is clearly needed.  But, that low cost must be coupled with reasonable, evidence based,  coordinated, and quality care.   The Timex watch might be a better model for US healthcare than the Cartier watch.

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What Do You Like About Doctors?


Everybody complains about doctors or other health care providers.  But, according to a survey by Consumer Reports last year 75% of 49,000 people surveyed were very satisfied with their doctors.  If you search the Internet that view is not obvious (go ahead, try a search).

So, it should be easy to see what people like about health care providers since so many people like what they do (or at least some things they do).

Leave a comment about a very specific thing your health care provider, or surgeon, or specialist, or hospital or clinic really does well.

Ok, just a few rules:

don’t include names, don’t include things like personality or appearance or grooming

do include things that seem efficient, things that seem professional, a process that solved a problem quickly, comments that made you feel better, or anything that made you say WOW.

The intent is to let other people know what really good care looks like.

I will start the ball rolling — the first comments are mine.

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Accountable Care Organizations — fee for service decline

Payment of health care providers by volume of service (fee-for service) rather than quality of service is blamed by many as the cause of  high cost and low quality in the US health care system.  

A possible solution was proposed in 2006 as the Accountable Care Organization (ACO).   The concept is modeled after other advanced countries which have lower cost and higher quality health care than the US.  The idea is to pay a large organization (the ACO) to provide all the  care needed for a large group of people.  In other words, a per capita system, with payments not related to volume of services.

 Medicare and the Affordable Care Act are betting on ACOs.  The private sector is moving that way as well.  The following graph shows the number of ACOs in the United States (CMS data)
aco map 2012

The following graph shows the increase in the number of ACOs starting in 2009 and ending the first quarter of 2012.

Rising Number ACOThe insurance industry is so entrenched it is hard to think outside of terms like deductible, out of pocket cost, and premiums.  And, current ACOs indeed use those terms.  But, under the hood, the ACO is run with a budget based on the cost to take care of a person for a year.

So, perhaps sometime in the near future you will just purchase health care by the year — something based on your age and ranging between $100 and $400 per person per month.  Undoubtedly, there will still be some co-payments in order to avoid over use of services by some people.

A well formed ACO has a strong focus on a medical home and should include pharmacy service (not Walmart,Target or Walgreens etc.), hospital service (not every hospital), doctors, nurses, physician assistants, x-ray services, medical equipment, and devices.   Not every hospital in the ACO would duplicate services — some would have specialty expertise, like brain surgery or heart surgery.

The materials to run the ACO would be purchased in bulk.  The providers would be predominantly on salary and the hospitals under a strict budget with  mandatory quality levels for all.

The rise of ACOs is encouraging but the actual number of covered patients is not large and the internal payment for ACO  providers is still rooted in volume of services.  But, with time and pressure (mostly from the business community) ACOs should begin to lower costs to levels enjoyed by other countries.

Congress could speed the process to be ready for the aging baby-boomers.  But, action in Washington seems nearly impossible.  It seems hard to argue against lower cost and higher quality, but they will.

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US Health-Care Costs — comparison of states

2009 Health Care Spending Per Capita

The graph is based on 2009 data from the Centers for Medicare and Medicaid Services and displays the spending in dollars per person.  There is a spread of costs from state to state.  Key drivers for any state include spending for hospital care, prescription drugs and physician services.  Utah has the lowest spending with outstanding performance in all three areas.  Utah has an advantage of few smokers, few drinkers and few obese people.  The explanation in other states is not so clear.  States next to each other like Georgia and Florida have extremes of spending levels not easily explained on demographics.  Florida has high spending like the Northeast probably representing a migration of both doctors and patients with a culture of high cost services.  One would think Utah demonstrates the best efforts of US healthcare with favorable demographics.  But consider other countries.

International health care spending

In the light of other countries Utah should probably be more like Sweden that has spending of $3722 per person.   The public spending alone  in the US should be achieving good health care for everybody but sadly that is not the case.  Our overall health-care spending is so much higher than other countries it makes the state to state comparisons seem less important.   But, the US needs a goal.  So, lets take a shot at the goal:  every state should have a goal of $6000 per person like Colorado.  Well, Congress — get to work!

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