Wednesday, August 26, 2009

Health Scare Tactics

My patient S______ was one of my best friends. We shared the same birthday and much more. S______ lived alone in a local residential care facility for seniors. I was not aware of any other visitors other than myself. She felt I was like a son to her. Often, she patiently listened to my personal struggles, giving me motherly advice and understanding. I enjoyed hearing about her memories of youthful exuberance and experiences, like watching the Enola Gay take off on its fateful doomsday mission from a base in the Utah desert.

S_____ ’s last days were not too much fun for her. Her family chose to ignore my recommendation to let her live out her last few months in peace. As a former Hospice Director I am familiar with relative’s struggles at this critical time in their loved ones lives. Their decision to drag S______ all over Salt Lake City (it was painful for her to get around) to see a handful of expensive specialists for a second opinion was understandable, especially when they seldom came to visit her. But, was it necessary, or wise?

S_____ suffered from multiple organ failure. Her heart, kidneys and lungs were barely keeping her alive. I had been treating her conservatively with a high dose water pill, narcotics and oxygen. She was comfortable and even looked forward to joining her beloved husband, whose smoking was the principal reason for her health troubles. After approximately $20,000 worth of testing and doctors’ fees, the recommendations for aggressive dialysis and more drugs thankfully fell by the wayside, yielding to common sense. S_______ was able to enjoy a few weeks of peace before she finally passed away.

I am afraid that S_______’s story is all too common… and too expensive. Roughly 40% of our health care expenses are wasted on misguided and often guilt-driven trips like S______ ‘s that cannot avoid the inevitable. Yet, it seems like an attempt to stop this madness is viewed by some as “death panels.”

While not spending enough to comfort our loved ones’ suffering at the end of life is just as reprehensible, cooler and more mature minds must prevail to strike a happy medium. After all, soon, it will be you and me in S______ ‘s slippers.

In my opinion, there are many other outright lies being thrown around in the health care debate raging in our country.

Please, keep you eye on the ball: we need to help alleviate the suffering of millions of Americans, some of whom get very little health care, if any (compared to S_____ getting too much.) We must not be blinded by the ideology and self-interests of the “man behind the curtain.” Insurance companies and Big Pharma have a nasty habit of planting misinformation designed to confuse Americans. These institutions, which originally set out to do good now are focused on doing well. Remember the controversy over Canadian drugs? Well, it was fueled by Big Pharma: Canadian drugs are safe and cheaper and will continue to be so, unless we wise up and put people first, ahead of corporate interests.

The British are upset that the debate in our country vilifies their beloved health care system.[1] So are the French and Canadians, who view our scare tactics to brand change as “communist” as a moral outrage. I agree.

Lest you think I am spewing partisan politics, let me say that I find President’s Obama’s secret meetings with the Insurance companies and Big Pharma reprehensible, albeit predictable. By now you may have heard that deals have been struck with the big boys to assure them that their profitability will be maintained.[2] While I understand Free Enterprise and profits (I love Adam Smith) I feel they must never be at the expense of our community’s health.

Mr. Obama’s pragmatism is understood and even necessary. No doubt the final draft of health care reform will include provisions to keep big business happy. But, let us not lose tract of some simple facts:
  1. A Public Plan Option will not discourage competition. How could it? Have you not seen the massive negative response from those who feel any government-run program is of the devil? Surely most of those Americans will choose not to join such a plan, just like many of them never use the US Post Office (which continues to hemorrhage money, unaided by the Feds,) preferring Fed Ex. Surely most of them also don’t use public schools or public parks, preferring private schools and open spaces within their gated communities. Excuse me if some of that opposition does not enjoy those affluent perks; I often wonder why people oppose any program that would expand their choices and services. Many seem to defend the interests of those who already have it made in the shade. I will continue to wonder, even though I know the answer: “keep the government out of my life.”
  2. The government is already involved in Health Care. The “single-payer” systems called Medicare and Medicaid have overhead expenses estimated to be less than 5%, while the “better run” private insurance companies’ overhead is anywhere from 15-30%.Very few doctors choose to participate in those programs. Doctors will not go for any system that threatens to “employ” them; a Public Option Plan would not. The government is already deeply involved in private insurance, too. This is the only reason such a dysfunctional system works at all. If left to their own devices, the big boys would do even more antisocial things, beyond their cherry picking healthy patients and denying payments. The present employer-based coverage is possible because of government intervention: tax breaks make it workable. By the way, I feel this is a mistake; it hinders competition and burdens a vital sector of our society with the moral obligation we should all be shouldering.
  3. Health Care rationing will always be part of any system we choose. It would be naive to think otherwise. Right now we choose to ration health care by leaving out in the cold 47 million Americans. Other countries choose rationing by covering the most essential of services for every citizen, and leaving “boutique care” uncovered or delayed by a “waiting list.” Such care is still available to those who can afford it, and/or are able to wait for it Those “communist” systems spend half of what we spend on health care, yet, they lead the world in health care parameter like longevity. Their citizens are more satisfied with their imperfect systems than we are with ours.
  4. “Follow the money.” We must recognize that our national preference for a capitalistic system will always result in “shadow governments” by wealthy, amoral elitists who cannot fathom extending a helping hand to those who suffer. While I agree we need to avoid a “welfare state,” we cannot morally or economically afford to deny essential necessities to the less privileged segments of our society. Let us not be so naïve to think that only one political party is in the elitists’ pockets: they both are. For instance, “blue dog” democrats who oppose a Public Plan option have been documented to get significant financing from Big Pharma.[3]
  5. There will always be dissatisfaction. When we choose “guns over butter” we must live with our choices (see “rationing” above.) The only reason most Americans seem to be satisfied with the present system is because of government intervention in regulating the insurance companies. “If you currently have decent health care insurance, thank the government.”[4]
  6. No health care reform will work, unless we shift our focus away from expensive, inefficient and ineffective treatments. We must focus on preventive services (like nutrition) that work on the root issues, not the symptoms.[5] Read my previous blog.
  7. We should have never abandoned the “not for profit” model of health care. Health is not a business; it is the moral obligation of healthy, mature societies who are able to balance profits, business with healthy governments that are not in the pocket of special interests. In my home state of Utah, health care used to be in the hands of churches; what a sad day when their mercy, compassion and “communist” thinking gave way to business-run health care…
  8. We face a moral issue, not a business issue. Please, keep this in mind as the debate rages.

    [1], August 14th 2009
    [2] J. Business Week August 11th 2009, cover issue & Salt Lake Tribune, August 13th 2009.
    [3] New York Times, August 2nd 2009
    [4] Paul Krugman, New York Times.
    [5] “Promoting More Conservative Practices,” JAMA 2009;301:865

Monday, August 17, 2009

Health Reform from Utah: We Must Focus on Health, Not Disease

"The following is a wonderful statement put out by a committee organized by the State of Utah to reform health care. I was privileged to be part of this committee." - HR

A Challenge and a Declaration

There will still be an enormous crisis in the health of Utahns and the rest of the Nation even if any existing health care reform plan in the United States is fully implemented and funded. No amount of money being poured into the health care system as envisioned in any current plan will generate the healthy individuals, families and communities in Utah and the Nation that we all aspire to achieve. Obesity, lack of fitness, poor nutrition, at risk behaviors and low coping skills for dealing with stress and social and emotional issues are not adequately targeted for reform. Without these factors being more fully addressed, the continued effort to increase services will eventually bankrupt the system, and leave the population remaining unprepared to take adequate personal responsibility to improve their own health. There are powerful evidence based approaches for supporting people to become more responsible for and successful in achieving improvements in their own health and well being. These types of knowledge, support, and culture should be embedded in the very fabric of our communities as well as in the health care system. With proper support the innate capacity for personal wellness increases, and with it, the tendencies towards greater individual and collective resilience can be seen. In addition there is a complementary science and art for creating healthy communities which generate a flourishing of society that is greater than the sum of the healthy individuals within it.

Unleashing these capacities in our communities should comprise up to half of the health care reform equation because this approach would create healthier communities, greater individual health and well being, be sustainable and effectuate reduced demand of health care services. Unfortunately wellness self management and healthy communities currently receive perhaps one percent of the attention in health care reform and less than that of the available funding.

Representatives of virtually all of the groups in Utah working on wellness self management including those involved in private sector programs, public health, health provider groups, and research convened in a summit meeting in Salt Lake City to begin to collaborate. They achieved perhaps for the first time universally shared Consensus Principles in this area, identified many best practices for evidence based approaches, and agreed on a common phrase for their shared work: pursuing healthy communities through “wellness self management.”

They have formed the Healthy Communities Wellness Self Management Network. The HC WSM Network will first of all be attempting to change the narrative around health care reform and bring attention to this “crisis beyond the health care reform crisis.” It challenges the people and leadership of the State of Utah to come to better recognize their own capacities for welness self management, the creation of healthier communities and for all of us to better come to grips with our own responsibilities in this regard. The Network is also becoming an active learning community, interconnecting existing programs and projects. It will support new demonstration projects and public policy which reflect Consensus Principles and evidence based approaches to wellness self management and healthy communities.

The people of the State of Utah are invited to join with members of the Healthy Communities Wellness Self Management Network and endorse the following Declaration:


Whereas, we pride ourselves in Utah on our spirit of self reliance and personal responsibility as well as our strong sense of community; and

Whereas evidence based principles and approaches of wellness self management and patterns of healthy communities have been established; and

Whereas, health care reform in Utah and the rest of the United States to date has tended not to emphasize such principles, approaches and patterns.

NOW THEREFORE: It is hereby resolved:

It is time for us to step forward and achieve healthy communities and wellness self management in Utah in a way that dramatically transcends all prior approaches to health care reform and unleashes our individual and collective capacities for creating the healthiest people and communities in the Nation and the World.

In doing so, we will cooperate extensively among the entire health care system together with communities, schools, businesses and other concerned organizations to institute and extend the means necessary to achieve a significant reduction in demand for health-care services through greater individual and community-wide responsibility.

Monday, August 3, 2009

Bridging the Environmental Gap Between Republicans and Democrats

Article submitted for publication in the Utah Medical Association Bulletin.

Serving as the Chairman of the UMA’s Environmental Committee has been an honor and a valuable learning experience. When I first assumed the position I thought that the data on environmental pollution and its negative effects on human health were evident, clear and irrefutable. I felt the same about the solutions to those problems.

I am certain that my passionate stance on these issues were not well received by some in the UMA membership; which is why I gradually came to understand that the data on environmental health may no be as important as the beliefs and political persuasions of those who read it and interpret it. It also became obvious that I, too, interpret environmental data through the prism of my own beliefs, political leanings and past experiences, just like everyone else.

[No doubt some physicians will disagree with the concept that objectivity may take a back seat to subjectivity in a field like ours. I can only say that being aware of these natural tendencies is the best way to maintain an evidence-based approach in our line of work.]

Gradually, I became more willing and able to re-examine the environmental data while considering my colleagues’ contrasting interpretations in mind. Consequently, I have learned to pick my battles, spend my political capital more cautiously and reach consensus more readily for the greater good. (My, I sound like a politician…) Yet, I still feel the UMA could be more proactive in environmental health issues, but I would rather march slowly with the UMA than faster all by myself.

My willingness to compromise and be open to others’ ideas has helped me conceptualize a problem I find is interfering with our mission to maximize the health of Utah citizens. In my opinion, strongly held ideologies on both sides of the political aisle are slowing down the implementation of environmental policies and regulations that have the potential to mitigate many of the health care problems we see in our state.

As a general rule, Republican doctors may be mistrustful of government regulation and Democrat doctors may demonize polluting industry and businesses while dismissing any economic compromises. While there is a grain of truth in both stances, extremist views don’t allow for a compromise that may better protect our patient’s health when it comes to environmental issues.

These are the reasons why I was delighted to come across T. Boone Picken’s plan for environmental policies in our country. Mr. Picken, a very wealthy industrialist, feels that our NATIONAL SECURITY should be the #1 concern as we contemplate energy policies that impact our environment. He agrees that we need to stop our “addiction” to oil that puts us in harm’s way from hostile oil-producing countries. But, he feels that our energy infrastructure is not ready to make the transition to non-oil sources, except for NATURAL GAS and WIND POWER.[1]

By making national security the sine qua non (or prima non nocere if you wish) of environmental issues we are likely to satisfy a justifiable concern that has arguably become a Republic issue. By focusing on wind power and natural gas we are likely to satisfy Democrats who arguably have been “greener” over the years.[2] A national security approach would also be mindful of sustainable business and economic concerns, arguably Republican platforms. Right now, fully 1/3 of our national income leaves our country to buy foreign oil. Keeping that money home would also make us stronger and less vulnerable. Since the Cold War ended by a “technical economic knock-out” (the US economically defeated the Soviets) we are seeing more “financial wars,” or Trojan horse strategies to weaken the opposition from within. China’s agenda comes to mind…

Since our oil addiction has been one of the most serious factors behind our dollar’s decline, it seems imperative to tie our energy policies to sustainable and locally produced energy sources. If push comes to shove, what would we choose: continue to send our young people to die in hostile lands to secure oil sources; or arguably, “somewhat-theoretical” environmental health data linked to an increase in the risk of chronic illness? Since said data is viewed differently by Republicans and Democrats, it seems prudent to me choosing to avoid the sure, immediate death of our soldiers (acute care) while striving to reduce the more subtle and drawn out (chronic care) effects of environmental toxins by developing natural gas, wind power, and other cleaner energy sources as their technology mature.

I hope that as UMA doctors we are able to find a comparable and mutually satisfying middle ground from which to act on the emerging data on environmental health problems in our state.[3] It is our calling to do so.

[1], or
[2] Mr. Nixon, a Republican, created the EPA. By the way, given the recent EPA’s endorsement of California’s policies on vehicle exhaust emissions (35.5 mpg and 40% better fuel economy by 2016) and several other policies through the years, the UMA’s environmental committee strongly recommends that the UMA support the EPA’s general philosophical approach to reducing air pollution.
[3] Go to “info by location” to find Utah’s page.