The Craven (short version)

Once upon a March so dreary,
The High Court pondered weak and weary,
about the future health and fate of many,
but had no dog within this hunt,
knowing they would never suffer any healthcare want.

The telltale heart that echoed loud,
that began the stirrings in the crowd,
came not from under any floor,
but beat from the chest of an infamous boor,
the meaning true both new and old,
the timing of this event to many, particularly cold.

A young man’s death grants him life,
after a lifetime of sowing none but strife,
other priorities were always present,
to prevent him from serving in jungle or once fertile crescent,
feeding off the blood of lost youth,
once just metaphor, now it’s truth.

What timing is this that points so boldly,
as a right wing Court considers coldly,
whether to strip away any safety net,
from those with fewer means whose fate by economics is so cruelly set,
What say the Republican’s on this sad score?
Market forces, and nothing more.

The black suited pundits and lawyers came a knocking,
knocking on the High Court’s door,
armed with briefs payed by other fattened suits,
and with the payors deep in cahoots,
to defeat the reforms was their charge,
with success would their golden parachutes enlarge.

Many asked with pleading eyes,
of future plans could the conservatives us apprise,
will something better come our way,
if you are able this chamber to sway,
If the black hearts this reform defeat,
can we something from you better beg and entreat,
Quote the Craven, nevermore.

LIARS!

LIARS!

I think most of the tiny segment who read this blog know that I prefer civil conversation but there are times when enough is enough. I despise liars. In my profession it is intolerable to lie considering the stakes involved. Wish it were so in politics.

There are many questions that need careful debate and consideration before we set on a healthcare reform plan. But liars are setting the agenda.

Case in point: Representative Earl Blumenauer (D, Oregon 3rd) added an amendment to the healthcare reform package being discussed in Congress. It was an addition that was universally favored by healthcare professionals and advocates of the elderly Simply stated it allows for reimbursement to clinicians when they have end of life discussions with patients in their offices. This is important legislation for a number of reasons.

As a physician I have seen the havoc wrought to patients and families when end of life issues don't get hammered out before it's too late. A lot of suffering and heartache is the result when the wishes of a patient are not known and respected. A lot of futile and expensive care gets provided to those who would not have wanted it if someone had bothered to have the conversation with them when they were alert. Physicians are not required to provide futile care but in the end it sadly is seen as far easier just to do it rather than trying to explain the subtleties of futility in endless depositions and to armies of lawyers over the next several years.

All hospitalized patients are required to have a 'code status' determined in writing when admitted as part of the metrics used to determine 'quality of care'. In the absence of information it is an American legal presumption that people would prefer to try everything to live unless otherwise recorded. This contrasts to Great Britain where just the opposite is presumed.

What Earl Blumenauer's amendment does is finally pay clinicians to provide counseling services to patients so that they can make informed and prudent plans for unfortunate contingencies should they arise. This is a very good thing. It gets the need for these conversations out in the open where it needs to be. I know from 20 years of experience that having these conversations helps both the patient, their families and their care givers. It results in more appropriate and humane treatment of the elderly. (There is a fine line between preserving life and prolonging suffering that all clinicians know too well. We have seen far too many people on the wrong side of that line.)

It's also a good sign that emphasis is finally being shifted toward true healthcare rather than our system of sick care. Caring for the overall needs of the individual rather than just trying to patch them up when ill or injured is a laudable goal that has been hampered by a lack of financial support. As the old saw goes, "an ounce of prevention...". Valuing the important work of counseling patients is an important part of healthcare reform.

It is not euthanizing the old. To say that it is - is a lie. And a particularly hateful and crass one at that.

All around the country ads and emails are flying claiming that this is a plan to euthanize the old. That is a lie. The people that started this rumor are liars.

Absent a plan of their own, or beholding to special interests who line their pockets, the opponents of reform efforts have nothing to offer but lies. Do yourself and everyone else a favor - call them out as liars.

As I said, there are plenty of issues to debate about healthcare but lies and liars have no place at the healthcare table. In 3 years the baby boomer generation starts reaching Medicare age. Unless something other than neocon bashing or insurance industry pandering gets done before then, the country will be on a slope to bankruptcy.

Mind Games: How Might the Founders Have Approached a National Health System?

And now for something completely different... Ignoring the likelihood that they would have punted such matters to the States, I sometimes try to imagine how the Founders might have approached some of our modern problems. What might they have envisioned? They had their faults but never the less were brilliant political thinkers.

We know that they were schizoid about centralized power. It was important from the perspective of having a coherent union but also dangerous from the standpoint of potential for tyranny. (I think they would have hated Medicare.) They looked to the States to provide a better insight into the lives and direct needs of their populations and to check the run away growth of centralized authority. To a large extent the States were free to experiment as long as it didn't interfere with the common cause (not always a good thing). They did not trust the individual to do the right thing.

Is that enough to imagine the rough outlines of what they might have done? Let's take a stab at it. Here, the incongruent forces are the best interests of the individual patient and the rights and responsibilities of those who provide medical services balanced against being respectful of the societal burden of the program, both now and in the future.

The Founders had a pretty good model of strong centralization with checks and balances - our three branches of government. One, closely linked to the will of the people and empowered to determine the rules; one to administer the program and weed out new rules that might be a bit hanky; and one, distanced from the people's whim to oversee the other two and make sure the rules fit with the intent of the governmental blueprint. Not a bad model for an important program.

Could this be the model of a national health system? It's fun to consider it for a moment. Start with a simple blueprint of clinical medicine with the needs of the patient at the core. Something that includes:

"We hold this belief to be self evident that all persons in a great and just nation should be granted benefit of basic healthcare. That the purpose of this national health system is to provide clinically relevant care to all in accordance with only those limitations that threaten long term solvency, or are contrary to the science of medicine. That privacy, being critical to the free disclosure of vital medical information to the clinician, shall not be violated save in circumstances, well defined in these articles, that threaten the common health of our citizens. That clinical workflow takes precedence over administrative workflow except to the minimum required to maintain solvency and ensure patient safety. That outcome is a amalgam of patient responsibility, clinical services, societal limitations and disease science. This charter defines three branches of the national health authority: Regulatory, Governance, and Clinical Oversight."

Things like that.

Regulatory would be charged with creating the rules governing the financial and common practices. Governance would administer the program and its payment and service structure. And Clinical Oversight would consist of a judicial system of medical experts empowered to ensure that the medicine never takes second place and enforce accountability of the other two arms.

I know, its simplistic, but.....

Down the Rabbit Hole: A New Model of a National Health System, Part 1

Healthcare is a hot agenda item with the new Obama administration. That's how it should be. With the costs associated with care and the millions of Americans either un or under insured it needs to be fixed. Recently Mr Obama announced a plan to ensure the the universal application of electronic health records in this country as part of his package of reforms. And with that bit of sagely advise that he got from the Harvard folks I have begun to get serious gastrointestinal upset. I'm seeing early warning signs that the Obama proposals are going to be a rehash of what's come before. And trying to prevent this is that to which I have dedicated the last 20 years of my career. The science of healthcare delivery systems is what I study and how I make my living such as it is. It is my passion and my mission.

Many of the people with whom I work would have a cow if they knew I was about to launch into a conversation on this particular topic. My academic and industry work in the area is required to be more accommodating and diplomatic. There are always lots of feathers to sooth and endless meetings with 'stakeholders' and opportunities to create 'buy in' and a thousand other administrative platitudes that result in the appearance of progress in meeting minutes. Then there are the business interests that have a lot to gain or lose depending upon how the political wind sock is pointing. Lastly clinicians, patient advocacy groups payers, governmental agents, academicians, you name it point fingers to all the others as the source of the healthcare meltdown. Few are willing to admit that all have a hand in the problem and all will have to sacrifice something to fix it.

But here it's different. This nom de plume and blog site offers an opportunity to express the more controversial aspects of what this research suggests we should and can build. I'm a medical systems heretic and I love what I'm doing.

My previous post have largely been personal opinions experiences and thought experiments but on this particular topic I'm actually somewhat of an expert. Over the next few weeks and months I'm going to discuss key aspects of a sustainable and logical plan to create a National Health System. A System that could be the envy of the world. And we'll talk about why this electronic health record proposal could kill it before it's born. You see, I believe with all my heart that it's time for a National Healthcare System for the US. But not one like most people imagine... Anyone interested in seeing what's down this particular rabbit hole? I'll give you the first clue - it's not a single payer system. In part 2, I'll share with you what's wrong with that old single payer model.