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Disclaimer

The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

I also reserve the right to change old postings to correct errors, and to delete comments that include obscene language or that I deem abusive to me or other commentators.  If you are looking for a open mind, I suggest you consult a neurosurgeon.

Katrina Blog Project
Wednesday
Jan252006

The Medical Paradox

Kevin, MD comments on the state of health care in this country. He says "we can't have everything," which I take to mean that he feels the American public wants high quality healthcare but is unwilling to pay the price tag. All of the commentators on his site seem to agree with him wholeheartedly, and think that patients need to pay more and shoulder more of the burden of healthcare. I respectfully disagree.

I have been a doctor for 8 years now and I know I am in the minority when it comes to healthcare reform. In a previous post about HSAs I spelled out my position. Here I will emphasize a few points. First, all workers already do pay the full bill for their health care. Health insurance premiums are deducted from paychecks, and employers who offer health insurance factor in the cost of healthcare when they set the salaries of their employees. It has been proven in multiple economic studies that companies that offer health insurance pay lower salaries than comparable  companies that don't. No one should think for a second that the typical worker gives up nothing for health insurance. Anyone who thinks employees get a free ride on insurance should confront a worker and tell them that.

Take nurses. In a typical hospital, there are two types of nurses, staff employees and agency nurses. Agency nurses work for a nurse staffing agency that leases their services out on an hourly basis. Agency nurses are not hospital employees, and are paid strictly on an up-front cash basis, one shift at a time. They are essentially independent contractors, and are paid much more money per hour than staff nurses -- sometimes $10 an hour above staff nurses, or even more. Yet every staff nursem, if asked, will tell you that she chooses full-time employee status over the better money of agency nursing because she wants the benefits. She knows exactly how much money she is giving up in the trade. Yet most nurses choose staff-employment over agency nursing.

But the key point I want to make is that when it comes to health care reform, doctors are not often very consistent in their opinions. The typical doctor (such as those posting in Kevin, MD, and the site Kevin was quoting, Medpundit) is completely against nationalized health care. I know very few doctors who want the government to finance insurance for everyone. And yet . . . .

If you look at the activities of the AMA, you will find that one of the AMAs highest priorities is lobbying Congress for increased Medicare funding. Each year, Congress tries to cut reimbursement to doctors under Medicare. And every year, doctors furiously lobby Congress to get the cuts restored. I have never met a doctor in my life who thinks physician reimbursement under Medicare should be reduced.

Think about it. If doctors really and truly believe that big government is bad, shouldn't they be lobbying for a smaller Medicare? Shouldn't they be arguing the Medicare should be cancelled, and that Medicare patients should be forced to pay cash for their care? In Kevin, MDs blog entry, he quotes Washington Post columnist Robert Samuelson: "Medicare recipients should pay more of their bills." That means Samuelson, and presumably Dr. Kevin and Medpundit, want Congress to cut Medicare payments to doctors. That is exactly what they are saying. I know of no way to make patients pay more of their bill except to cut the Medicare payment.

That is the paradoxical attitude of many doctors have towards health care reform. On one hand, they are against government involvement in health care. On the other, they are against any cut in physican reimbursement. Since Medicare is a government program, they are  both in favor of and against the growth of  Medicare growth of Medicare payments.

If the doctors who support shifting more financial burden directly onto patients get their way, there will be fewer patients who can afford to go to the doctor. This is economics 101. When you raise the price of something, fewer people will be able to afford it. Demand goes down. In the end, this so-called beneficial shift will save taxpayers money, but it will also deny health care to millions of seniors. And yet, check the AMA website, even as some doctors push to decrease government payments for their patients,  they are working at this very moment to increase government payments to themselves.

I want to say parenthetically that I do not oppose the AMA's efforts to increase Medicare physician payments. But then, I am not the one calling for decreased  government involvement in health care.  

Conservatives often make good points when they argue that private businesses can provide services cheaper and more efficiently than the government. But in the case of health care, I do not believe it is so.  Private enterprise has had every opportunity in the world to provide cheap, efficient health care. What we have as a result is millions of uninsured, millions more unhappy with the insurance they have, and the medical community arguing that public health spending needs to be cut for the patient's own good.

I ask you: Is your health care cheap? Is it efficient? Do you trust it to be there for you for the rest of your life?

Tuesday
Jan242006

Katrina #7: Scorecard

The Associated Press is reporting this complete assessment of Hurricane Katrina’s damage:

                                                    Louisiana                             Mississippi

Deaths                                         1,100                                             200

People Displaced                 786,000                                     110,000

Destroyed Homes                217,000                                      68,700

Destroyed Schools                   835                                               263

Destroyed Hospitals                 10                                                   2

Businesses Closed                 18,800                                         1,900

Jobs Lost                                 240,000                                     46,000

 

I cannot find a list of the destroyed hospitals, but I can make a good guess on the 10 in Louisiana: Chalmette Medical Center, Methodist Hospital, Bywater Hospital, Lindy Boggs Medical Center (formerly Mercy Hospital), Lifecare-Chalmette, Lifecare-Memorial, Memorial Medical Center, Charity Hospital, University Hospital, Tulane Medical Center.

Of all these hospitals, only Tulane is currently being renovated for reopening. I was on staff at Chalmette Medical Center and Methodist, and worked at all the others (with the exception of Bywater) as a resident.

I will post pictures of my old neighborhood on my website soon, for the curious.

Monday
Jan232006

HSAs, Part I

The Health Savings Account, or HSA, is the centerpiece of conservative health reform today. Much as the new Medicare prescription benefit has descended on seniors, the HSA is a latest healthcare wrinkle that will probably find you whether you want it to or not.

An HSA is a personal savings account that can be funded tax free. The money in the account can then be invested, if the owner prefers, for growth. Any money, whether deposited or interest made on prinicpal, can be applied to healthcare expenses, again tax free.

Sounds pretty benign, but here’s the catch – to qualify for such an account, you have to enroll in a health insurance plan with a high deductible, what the government calls a Qualified High Deductible Health Plan (QHDHP). This means a plan with a minimum deductible of $1,100 for an individual and $2,200 for a family.

High deductible health plans have been around for a long time, and the can make sense for young, healthy individuals who do not see the doctor much. For a cut in premium of several hundred dollars a month, the insured assumes the cost of routine visits. Insurance only kicks in when there is a serious expenditure, such as an appendectomy or orthopedic surgery for a torn knee ligament.

Advocates say HSAs will help patients in several ways. First, they offer a tax break to those who are willing to assume some of the cost of their healthcare through higher deductibles. Secondly, HSAs will allow employers to offer health insurance to more employees, because the premiums employers pay for high deductible plans are so much lower. Finally, they argue that consumer driven healthcare, that is, healthcare in which the patient decides what to buy and how much he wants to pay for it, will drive healthcare costs down. A patient who has to pay for a tetanus shot out of his own pocket, for example, will shop around to find a good price. The weakness of the current system, HSA fans argue, is that patients never see the entire bill. They are not aware of the full cost of their care, and so have no incentive to shop around, or to dispute unnecessary expenses.

As a practical scientist, I am not against giving the HSA idea a whirl. HSAs will probably reduce healthcare expenses a little and will likely make insurance more affordable for some people. I am in favor of trying anything that will improve healthcare. The problem is, I think the benefits of HSAs are limited, and that this concept is only a temporizing measure that may slow but will not prevent the long term healthcare problems this country faces. In the interest of brevity, I will not tackle every concern I have with HSAs now, but will spread them out over several articles. I will spell out my biggest concern here and now.

HSAs will not extend healthcare to everyone. If we assume for the moment that HSAs will in one way or another reduce health costs (which is not proven), it follows that the savings can be used to insure more people. This is a good thing, but “more people” is not everyone. Though HSAs will make it easier for workers to afford insurance, it does nothing for the unemployed. The insurance may be cheaper, but you still have to buy the it, or get it from an employer. Let’s say a full policy costs $600 a month and a high deductible plan costs $350 a month. A premium of $350 a month, or $4200 a year, may be an affordable option for someone who drives trucks for a living, but for a cashier at Denny’s who makes minimum wage, it may still be unaffordable. Extending healthcare coverage to a greater number of people is a good thing, but not at all the same as extending healthcare coverage to everyone.

Here I think is the greatest disconnect in the healthcare debate. There are some people who think health insurance is a personal right that should be extended to everyone, regardless of their ability to pay. There are others who think it should be available to everyone as a choice, but it should not be legally mandated. The choice people believe that our only responsibility is to make access to healthcare inexpensive enough so that everyone has a fair shot at getting it. The rights people think as long as someone is left out, for whatever reason, that injustice is being committed.

I am a rights person.. As a doctor, I spend most of my life’s waking hours helping people overcome the scourge of disease. The care system I am part of can help anyone and everyone, and I am opposed to any approach to healthcare that would leave anyone out. It does not make sense to me that a system dedicated to helping people should select who it helps depending on his or her ability to pay.

Purists like to look at the Constitution and the Bill of Rights and say there is no mention of healthcare as a personal right. No, there is not. But our country is built on the assumption of equal opportunity and social mobility. The freedom to compete on equal footing with others and rise out of poverty is the very heart of the American Dream. We do not consider it just that a child who grows up in the ghetto should be required to go to a terrible public school while one who lives in a wealthy suburb gets to go to a good one. This does happen in America, but that is not to say that we endorse it as right.

In the same way, access to quality healthcare is very important if individuals are to compete on a fair playing field. Why would it be fair that a man from Upper West Side New York can have his asthma properly treated, allowing him to continue to work, while a minimum wage earner in the Bronx goes untreated, resulting in missed work days and eventually in the loss of his job?

From a Constitutional standpoint, it is not obvious that everyone should have healthcare insurance. But from a moral standpoint, it is. Allow me to turn the question on its head: If everyone is not entitled to health insurance, who should be excluded? Should the lazy, or the uneducated, or the immoral, or even the downright evil be excluded? In out country even imprisoned murderers have access to doctors. It is one thing to say that a lazy unemployed man should be denied luxury housing, or a car, or a steak dinner. But how long, in the richest nation in the history of the world, should he be allowed to cough up blood before he gets an X-ray? If the U.S. can’t afford to care for everybody, then hang it up – no one can. The problem is, poorer nations can afford it, and they do.

Giving everyone the opportunity for good healthcare isn’t just good ethics. It is good business. As I noted above, a large part of the American Dream is about giving everyone who wants to try a fair shot. Good health is a basic possession that frees people who want to better themselves to go out and do just that. By giving everyone healthcare access, we unloose the full creative force of America. A healthy workforce is a productive economy. I think even the staunchest conservative would have to admit that our economy would benefit from a work force that is medically fit.

And that is the problem with the HSA. It offers healthcare to more people, but not all of them. Both morally and economically, it falls short.

Friday
Jan202006

My Big Fat Green Gas Guzzler

main_g35.jpg

I’ll admit I suffered a twinge of liberal guilt when I bought my last car in November. I went for an Infiniti G35, one of Infiniti’s low-end models but hardly anything to be ashamed about. Moon roof, 280 horsepower, standard leather interior. Its drawback is relatively poor gas mileage – about 18 in the city. My last car was an Infiniti, and after I bought it I promised myself my next vehicle would be a greener model. Maybe one of those hybrid jobs.

Hurricane Katrina threw me off of this plan, as she has off of so many others. She killed my old G35 in its infancy, after only 15,000 miles and 18 months of service. I knew when I left it behind I would never see it again. But I was afraid to evacuate New Orleans with my family in two cars – we might get separated in the traffic – and the other car was larger and could carry more stuff. That is another story.

When I came back after the storm and verified that my poor car had taken on 12 feet of water, I reacted like someone who just lost a beloved pet. I had to have another one, just like the last. The green promise went out the window. Oh, I tried. I thumbed through many a car guide. I even subscribed to the on-line Consumer Reports new car guide and ran every model I could think of against the G35. Had to have it. It was more a matter of putting things back the way they were, than any consideration about what was the best car. So I bought it, and screw the environment.

Lucky for me, my petty liberal guilt was assuaged by a column in the Wall Street Journallast week. In speaking about so-called “green” houses, the author, architectural critic David Akst, pointed out quite acerbically that green is relative. He noted that most green homes are single-family dwellings with high square footage. What is green about a 15,000 square foot house, he asks, even if it is solar heated? You still have to chop down and process trees, chemically treat wood, manufacture paint and plastic to build a house. The bigger the house, the more natural resources have to be consumed.

Green is small, a mobile home, for instance. No one with the resources to build green builds modest. Green houses are usually ostentations mansions, and thus a waste of building materials. A real green building is a tenement with 600 square foot apartments, or a house with 3 families living in it. Efficiency makes something green, and efficiency does not mean solar power. It means people living modestly, in close quarters.

Akst makes the point that people who design and live in green houses often make lifestyle choices that negate the benefits of the houses. For instance, a green home that is a 2-hour commute from work is hardly green, is it? Even if the owner buys a hybrid car that gets 60 miles per gallon, the wear-and-tear of the commute uses up the car, meaning more frequent oil changes, battery changes, new tires, and in the end, a new car at an earlier date.

Which brings me to my green gas guzzler. I live in a small country town, and my office is literally next to a cow pasture. My house is 7 miles from my office, and I can make the drive in 9 minutes flat. I fill up my tank once every 3 weeks. Who is greener, I in the country gas guzzler or the Los Angelino who lives 25 miles from work, takes 70 minutes to get there, and owns a hybrid but still has to refill the tank every weekend? Even if he carpools, the Angelino will have a devil of a time keeping up with me. And if I turn off my air conditioner and open my moon roof, well, he’s whipped.

So I am green after all. Not green because my car gets low mileage, but green because I have made a lifestyle choice that permits me to use less non-renewable resources. Green is not about what you choose to buy. That is mindless, consumerist thinking. Green is about how you choose to live.

Wednesday
Jan182006

The Chocolate Crescent

By now people nationwide are familiar with New Orleans Mayor Ray Nagin's comments on Martin Luther King Day. For those who haven’t heard, I’ll summarize. Nagin got in trouble for two separate comments. First, he said that Hurricane Katrina hit New Orleans because “God is angry with us.” Second, he said that New Orleans was a “chocolate city” before the storm, and would be a “chocolate city” again.

The “chocolate city” remark probably has gotten the most mileage, because it is the easiest to ridicule. Referring to black people as “chocolate” is in some circles mildly demeaning, and in others is used endearingly. Sometimes it has sexual overtones, as in “I’m gonna get me some chocolate tonight.” Either way, it was an oddball way to open a political address. I doubt Nagin meant anything by it. I think it was just an attempt at humor. All politicians need to attend a comedy workshop, where they can learn the golden rule of comedy – LEAVE IT TO THE PROFESSIONALS. If you don’t know how to be funny, don’t try. There is no easier way to look stupid than to make ill-timed stabs at humor.

As for the “God is mad at us” argument, this is really peculiar. More than one religious conservative has taken his licks from the media for issuing the old the-victims-must-have-deserved-it argument. For him to have touched this tar baby seems colossally stupid. What was he thinking?

I happened to hear part of Nagin’s speech live on the radio, so I can tell you what he was thinking. He was trying to pull of an imitation of Martin Luther King. His speaking style and vocal intonations were straight from the pulpit. He even went into a long and sometimes confusing reverie about seeing Dr. King in a dream and asking him his opinion on how things were going here on earth. It was hard to tell sometimes if Nagin was talking, or if he was paraphrasing the advise of his imaginary Dr. King. And of course that is leaving aside the question of if Ray Nagin would even know what King would say if he were alive. Does he really know?

Nagin is a businessman by trade. Martin Luther King was a Baptist minister, and one of the best orators this country has ever seen. Nagin would have had an easier time strapping on a pair of Nikes and imitating a Michael Jordan highlight reel than trying to approach King’s speaking style. I still get chills every time I hear the “I Have A Dream” speech, and I have heard it hundreds of times.

In trying to imitate King, Nagin drove himself into a difficult situation. He tried to weave King’s powerful sense of faith in God and divine morality into his words. Dr. King’s speeches were all about morality, and faith, and purpose, and he did it better than just about anybody. Mr. Anybody Politician can’t just put that mantle on like a Santa Claus suit and prance around for everyone’s pleasure. King got shot for saying what he said. If you are going to imitate the Reverend, you had better be sure of yourself.

Nagin was just fooling around. He was doing an imitation for a mostly black crowd, a supportive crowd, and he was trying to make them feel good. He was telling them what they wanted to hear. But Martin Luther King never told people what they wanted to hear. He told them what they needed to hear, and the heck with the consequences.

Ray Nagin is not an articulate man. He dresses sharp, looks good, appears bright and educated, but when he opens his mouth the words come stumbling out like drunks out a Bourbon Street bar after last call. In a way, he reminds me of George W. Bush, who also looks like he should be articulate but isn’t. W has one huge advantage over Nagin – he has advisors who tell him what not to say.

If Nagin wants to study great oratory (and who doesn’t!), I refer him to Harry S Truman. Truman was not a great writer or orator, but he was effective because he knew his limits and spoke plainly and honestly. Truman rarely put on airs. He played himself, and had a very successful run doing it.

Ray, meet Harry. Harry, this is Ray.