Wednesday, November 25, 2015

Four Health Law Questions with Applied Math Answers

Mathematics may be defined as the subject in which we never know what we are talking about, nor whether what we are saying is true.

Bertrand Russell (1872-1970), Recent Work on the Principles of Mathematics

I read today what an advocate of the Health Law and what an opponent had to say about the effect of the law (Affordable Care Act’s Next Phase: Leslie Dach Says It Has to be about Quality, not Quantity”; “Sen. John Thune Says Republican Alternatives Do A Better Job by Relying on Market Forces, “ WSJ, November 24), and I decided to apply a little math. After all, as a sage said, “In God we trust, all others use Data.”

Leslie Dach, a senior counselor for HHS observes that since the Law went into effect, 17.6 million more people now have coverage, a 45% drop in the uninsured rate.

Yes, says Senator Thune, that’s true but the cost has been $1.3 trillion, and 35 million are still uninsured, and, according to the Congressional Business Office, there will still be 27 million uninsured by 2015.

The first question. Has the cost of covering 17.6 million over the last 5 years been worth it? If you divide $1.3 trillion by 17.6 million, that amounts to $73,864 for each newly insured person.

The second question. Is this $73,864 worth the massive disruption it has created for the middle class, tax payers, patients, physicians, and hospitals. If one assumes America has a population of 320 million. $1.3 trillion divided by 320 million comes to $4062.40 per person. Whatever happened to that original ObamaCare promise that the health law would reduce premiums for a family by $2500? Instead the opposite has occurred, with premiums up $4865 for the typical family.

The third question. Has the spike in costs translated into increased quality and satisfaction ? The American people as a whole apparently think not since the average of national polls indicate 43.4% approve of the law while 50.0% oppose it.

The fourth question. Here we leave solid mathematical ground, does centralized national government or decentralized market forces do a better job at reforming health care? The question is moot since only the first has been tried.

Leslie Dach claims government is better because it incentivizes to pay for “quality not quantity” by doing away with fee-for-service medicine and by incentivizing care to be “integrated and organized.”

Senator Thune insists markets will do better through interstate competition, reduced regulations, doing away with mandates, grouping small businesses into high risk pools, expanding health savings accounts, having states regulate Medicaid according to the particular needs of each individual state.

Who knows the answers? The ultimate jury, the American people, are still out, at least until 2016 and undoubtedly thereafter. Until then, as the Mock Turtle in Alice in Wonderland, remarked, there will be “Reeling” and “Writhing” in the different branches of mathematics – Ambition, Distraction, Uglification, and Derision.” In the modern era of digitization, another branch, Big Datafication, may hold the answer.

Monday, November 23, 2015

ObamaCare As Deck of Cards

Patience, and shuffle the cards.

Cervantes (1547-1616), Don Quixote

Trust everybody, but cut the cards.

Mr. Dooley (1867-1936), Causal Observations

Picture ObamaCare as a deck of cards with two sets of dealers.

Dealers on the Right

Dealers on the Right are predicting ObamaCare will collapse like a house of cards before Congress has a chance to repeal it. These dealers point to UnitedHealthCare’s announcement it will cut back on its health exchange commitments in 2016 and probably withdraw altogether in 2017. United's CEO says United simply cannot afford to lose $425 million as it has so far on the exchanges. Its investors won’t stand for losses of this magnitude, unless of course the Obama administration steps in and bails out beleaguered insurers.

Dealers on the right also point to the collapse of 12 of 23 health exchange co-ops, with the remaining 11 teetering on the verge of bankruptcy. And finally, they observe that the Obama administration is forecasting that less than half of those originally expected to sign up for exchanges will do so. And those who do sign on are likely to be the chronically ill with high expenses that will drive costs and premiums even higher.

Next year more than half the states on the exchanges will experience double digit premium rises, and the accompanying deductibles and co-pays will be unaffordable.

Hence, an impending "death spiral", not enough of the young and healthy enrolling, higher premiums for the remaining folks, less of the latter signing on, and the House of ObamaCare Cards will come tumbling down. And all the King’s ( Obama’s) successors and all the King’s Horses ( future CMS, HHS, and other government agencies ) will be unable to put Humpty Dumpty (ObamaCare) together again (Rick Manning, “ObamaCare’s Predictable Collapse,” The Hill, November 22, and Editorial, “ ObamaCare Imploding Even Before Repeal, “ New York Post, November 23).

Paul Krugman, PhD, economist and New York Times contributor), A Dealer on the Left

The Right’s argument, asserts Paul Krugman, is a stacked, unshuffled deck. Somebody needs to cut the deck, and he's the man.

Everybody in liberal circles, Krugnab believes, knows that the federal government holds all the cards. Government sets the rules of the game. CMS is by far the single biggest payer of them all. Government has those all important trump cards, and two more - compassion and the conscience of humankind," in its hand. The end game, in his mind, universal coverage, is now in sight.

ObamaCare is, Krugman insists, a “huge success story,” with 17.6 million insured on Medicaid and the exchanges, with only 30 million uninsured to go. Krugman knows of what he speaks. Among his 10 books is The Conscience of a Liberal, and he has written 750 columns for Slate, the New York Times, and like-minded left-leaning publications. The critics may double down on ObamaCare, Krugman believes, but they will be in double trouble because the Health Law will double the number converted from the uninsured to insured.

ObamaCare, Krugman concedes, “is an imperfect system, but it’s workable - and it’s working ( Paul Krugman, “Health Reform Lives!” New York Times, November 23). And so it is and so it does, at least for the moment and for the rest of Obama's Presidecy, and for as long as the people believe the government can be trusted, a period which may be drawing to a close.

Our Next President

Who do we think should be our next President?
We hold these characteristics to be self-evident.

He or she should be a person who is strong,
Not someone weak who simply goes along.

He or she should be a person of action,
Someone who acts decisively with passion.

He or she should not be a mere talker.
Not someone who is a passive sleepwalker.

He or she should be a person who talks straight,
Someone who is confident in political debate.

He or she should be proud of the good old USA,
Someone who believes our values are AOK.

He or she should not for U.S. be apologetic,
Someone who for our values is sympathetic.

He or she should focus on being effectual,
Someone who is no feckless intellectual.

He or she should aim at home for budget austerity,
Someone who combines growth with prosperity.

He or she should focus abroad on respect,
Someone whose motives are not suspect.

He or she should be a leader from way up front,
Not someone who lurks behind, afraid to confront.

That is who we want to be our next President,
That is the ideal person we want us to represent.

Sunday, November 22, 2015

Are General Propositions Worth A Damn?

I daresay that the chief aim of many is to frame general propositions but no general proposition is worth a damn.

Oliver Wendell Holmes (1841-1935)

Eliminating uninsured is a worthy general proposition, but price is often frightful for taxpayers, economic growth, middle class, and individual liberties.

Ending discrimination on basis of age, gender, and religion are fine general propositions, except for those who cherish keeping traditional values of their own kind.

Paying doctors for “value” rather than “volume” is rational general proposition, but it requires regulations based on impersonal big data rather than on personal wants.

Universally connecting individuals through the social media is powerful general proposition, except it may breed narcissism and ignorance of collective society.

Tolerance for other cultures is admirable general proposition, but other cultures may be intolerant of you and demand you to submit to their ideology or be extinguished.

Equal outcome for all is an idealistic general proposition, except that it ignores human ambitions, skills, and drive to rise above and improve the lot of the common herd.

The secular belief that anything goes is understandable and pleasurable general proposition, but it may produce addictions, degrade society, and create anarchy.

Going to war against ISIS is widespread reactive general proposition, but to kill or be killed has hazards such as what does it take to do the job and what do you do when you win.

Innovation and entrepreneurship are proven general propositions for creating prosperity, but progressive taxes and onerous government regulations retard their implementation.

The French call for Liberte!, Egalite !, and Fraternite! are desirable general propositions, but are not free and must be coupled with a commitment to Securite! whatever the price.

Ten Other General Propositions about Health Reform

One, the poor and uninsured will always be with us, no matter how noble your intent or intent your desire to alter the situation.

Two, to satisfy most of the people most of the time and to stay in office, you have to keep changing the rules to satisfy more of the people more of the time.

Three, to cover most of the people most of the time, you have to use Other People’s Money – the Have’s, the Young, and the Healthy – and most of this money comes from the Middle Class, not from the Rich.

Four, to cover most of the people most of the time requires a healthy growing economy: that economy may require progressives embracing an economic system they do not believe in.

Five, to make health care affordable and to protect patients against insurers’ abuse is not about covering routine care: it is about health insurance that protects patients with chronic high cost diseases against catastrophe.

Six, to afford people with equal opportunities are not the same as guaranteeing equal outcomes; to try to equalize the two is to try to reverse the laws of human nature.

Seven, to achieve successful reform you must grasp the reality that many people prefer personal one-on-one care from a physician to team-care from an institution or from government.

Eight, to judge the “quality” of medicine, or the satisfaction of care delivered, by data outcomes alone is a fool’s errand.

Nine, to think of the computer as the only effective tool for improving health care is foolish and simplistic; the computer is not effective for communicating many people, for many of the people you want to reach are not computer-savvy nor do they care to be.

Ten, to achieve effective reform, you must recognize that individualism and humanism are not always compatible with collectivism.

Saturday, November 21, 2015

Public Approval, Disapproval of Health Care Law

Real Clear Politics Average, 42.6 50.0.

Against/Oppose +7.4

Gallup 44 52 Against/Oppose +8

PPP 42 40 For/Favor +2

Rasmussen Reports 43 52 Against/Oppose +9

FOX News 41 54 Against/Oppose +13

Quinnipiac 43 52 Against/Oppose + 9

National Physician of the Year Awards

Each year in March, Castle Connolly, Ltd, a medical company in New York City, presents the Castle Connolly National Physician of the Year Awards. As a member of the advisory board of Castle Connolly, who publishes books and articles on America’s Top Doctors, I am called upon annually to help select two Lifetime Achievement and three Clinical Excellence Awards. Clinical peers and hospitals nominate the candidates.

The candidates are invariably specialists from major academic centers who have pioneered innovations, written hundreds of papers, been national leaders in their specialties, received multiple awards, led or served on national specialty or editorial boards of their discipline.

This year’s candidates

Lifetime Achievement Nominees

• Joseph S. Torg, MD, Temple U. Hospital, Orthopedic Surgery, Sports Medicine

• Hricak Hedvig, MD, Memorial Sloan Kettering, Diagnostic Radiology

• W, Gerald Austen, MD, Massachusetts General Hospital, Chairman, Cardiac Surgery

• Arnold Cohen, MD, Einstein Healthcare Network, Obstetrics and Gynecology

• David Apple, MD, Shepherd Center , Atlanta, Orthopedic Surgery

• Suzanne Oparil, MD, University of Alabama, Cardiovascular Disease

• Richard J. O’Reilly, MD, Memorial Sloan Kettering, Medical Oncology

• Herbert Dardik, MD, Englewood Hospital and Medical Center, Vascular Surgery

• Randall Olsen, MD, University of Utah and John Moran Eye Center, Ophthalmology

• Valentin Foster, MD, Mount Sinai Hospital, Cardiovascular Disease

• James D. Crapo, MD, National Jewish Center, Pulmonary Disease

Clinical Excellence Nominees

• William J. Catalona, MD, Johns Hopkins, Urology

• Fred Telischi, MD, MD, University of Miami, Otolaryncology

• Alice Yu, MD, University of California, Pediatric Hematology-Oncology

• Jeffrey Speigel, MD, Lahey Hospital and Medical Center, Otolaryngology

• Ihor S. Sawczku, MD, Hackensack University Medical Center, Urology

• Victor Navorro, MD, Einstein Healthcare Network, Hepatology

• Ross Zafonte, MD, Spaulding Rehabilitation Center, Physical Medicine and Rehabilitation

• Phillip Stieg, MD, MY-Presbyterian/Weill Medical College, Neurosurgery

• Eva Feldman, MD, University of Michigan Health System, Neurology

• Debra Somers Copit, MD, Einstein Health Network, Diagnostic Radiology

• Mark R. Katlic, MD, Sinai Hospital, Geriatic Medicine

• Kenneth Anderson, MD, Dana Farber, Hematology

• Everett E. Vokes, MD, University of Chicago, Medical Oncology

• Robert Spetzler, MD, University of Pittsburgh, Neurosurgery

• Anthony Atala, MD, Wake Forest Institute, Urology/Regenerative Medicine

• Ricardo L. Carrau, MD, Ohio State University, Otolaryngology/Head and Neck Surgery

• Alberto Esquenazi, MD, Albert Einstein Medical Center, Physical Medicine and Rehabilitation

• Mani Menon, MD, Henry Ford Health System, Urology

A Footnote

Specialists in academic medical centers are the sinews of America’s worldwide reputation for excellence. This event, the Castle Connolly National Physician of the Year Awards, is medicine’s way of celebrating excellence. I consider it Medicine’s Academy Awards.

While we celebrate this event, it is worth noting these specialists and hospitals they represent are under financial stress because of cutbacks in federal funding, reimbursements for specialists, and ObamaCare regulations. With the reduction in federal grants and these other factors, these specialists and hospitals must make up the shortfalls.

How to do this? Victor J. Dzau, MD, president of the Institute of Medicine and an academic himself (NEJM, "Transforming Academic Health Centers for an Uncertain Future," September 12, 2013) has these comments and suggestions.

“ In academia, it is no longer be enough to serve your local and regional communities or to have a cluster of world class specialty centers. It is no longer enough to attract National Institute of Health and other grants. It is no longer enough to have a series of independent specialized fiefdoms connected by a common heating system, a commodious parking lot, and buildings held together by a prestigious academic name. It is no longer enough ‘Publish or perish.’ “

Now, faculty members must “transform or perish.”

Dzau et all cite the following factors as having brought about this new state of academic affairs:

• ObamaCare regulations

• Reductions in Medicare and Medicaid reimbursement

• Driving of health plan enrollees to lower cost providers and into narrow tiered networks of physicians and hospitals

• Ending of government funding for hospitals treating low income patients.

The result is that academic centers are falling 30 to 40 cent short for every federal dollar needed to support their research and educational missions.

How to respond?

Dzau recommends these survival strategies.

• Balance specialized clinic excellence with population health.

• Combine “centers of excellence” with research translating that excellence into training for doctors.

• Become high-performing regional health systems ”spanning the spectrum from community-based and primary care to highly specialized hospital and post-acute care, all linked by effective information systems.

• Increase research yields by translating results so they have an immediate impact on practices and services offering natural economies of scale and fostering innovation and entrepreneurship.

• Offer new ways to engage patients, through e-healthy, mobile devices, and increased personalization driven by advanced data analytics.

• Require centralized enterprise-wide planning and management to prepare for an uncertain future.

• Centralize coordination and tamp down with faculty individuality and autonomy will not be enough to get the job done.