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Big Tobacco: A Government Scapegoat Favorite

Smokers of the world unite! It’s strange for a physician to be sympathizing with the tobacco companies, purveyors of the opium of the people. Am I a stealth nicotine addict, an apologist for Big Tobacco who supplies me with my daily fix? This scurrilous allegation can be vaporized in a one-question quiz:

Q: Identify which two of the three individuals listed below are cigarette smokers:

- John Boehner, newly elected Speaker of the House , 3rd in line to the presidency

- Barack Obama, Commander-in-Chief and leader of the free world

- Michael Kirsch, Hemorrhoid Examiner

I’ve never smoked and I detest the habit. It kills people and separates lower income Americans from money that could likely be devoted to more worthwhile endeavors. I remember caring for folks with end-stage emphysema as a medical resident and thinking that this disease was worse than cancer. I haven’t changed my mind.

Yet I have felt for years that Big Tobacco is demonized by the press and the government as Big Scapegoat, and this blame shift has always troubled me. I am well aware that the tobacco companies are guilty of many offenses. They have lied about their corporate practices, advertising strategies and manipulation of nicotine content. These companies — like any individual or business — should be held accountable with available legal remedies. If crimes were committed, then I’m sure this nation has a few idle and altruistic attorneys who can fight them in the courts. Read more »

*This blog post was originally published at MD Whistleblower*

Healthcare Reform: Then (1994) And Now (2009)

DrRich has been around long enough to remember the sequence of events that accompanied the collapse of healthcare reform under the Clintons in 1993 – 1994.  (Heck, he has been around long enough to remember Nixon’s plans for healthcare reform, which drowned in Watergate.) When President Clinton was inaugurated, everyone agreed that the American healthcare system was in a state of crisis (e.g., spending levels could not be sustained, there were too many uninsured, there was too much waste and inefficiency, etc., etc.), and that the time for fundamental reform had finally arrived. We had a fresh, dynamic, young President with new ideas and with a solid majority in both houses of Congress, and he was armed with polls showing that the people were in favor of fundamental reform.

Accordingly, when Mrs. Clinton put together her working groups to devise a reform plan, she initially had the enthusiastic participation of numerous interest groups within the healthcare industry – notably including the insurance companies, physician groups, and drug and medical device companies.

But when she finally produced her plan – a disturbingly heavy tome filled with frightening details – everybody was horrified with at least some of the stuff they found there. Most of the big interest groups turned on her – most notably, the insurance industry, which then launched the famous Harry and Louise commercials to scare the people about government healthcare. The people, now duly scared, called their congresspersons, who (despite the Democrat majority) ended up sending Mrs. Clinton’s healthcare reform to a crushing and humiliating defeat. And the Republicans were able to capitalize on the “near miss” of the Clinton’s brazen attempt at socialism, and in 1994 ushered in 12 years of a Republican majority in both houses of Congress.

Obviously, for those Republicans and other observers who abhor Mr. Obama’s plans for healthcare reform, it is relatively easy to see parallels between what happened in the early 1990s, and what appears to be shaping up now. Those parallels, and the subsequent ignominious defeat of the Clinton plan, are the only things keeping these sorry individuals from donning sackcloth, heaping ashes upon their heads, and engaging in public self-flagellation.

So, perhaps, for such outsiders the spectacle of the major private healthcare interests this week throwing in with the Obama administration will be seen as one more sign from the gods that the parallels of 1994 are falling into place.

But they are wrong.

There are at least three important differences between the enthusiastic participation of private interests in Mrs. Clinton’s working groups on healthcare reform, and the action taken this week by representatives of insurers, doctors, drug companies, hospitals, and medical device manufacturers to pledge their undying support for President Obama’s efforts at healthcare reform.

First, in 1993 the private interests were powerful and confident. They participated in the process because they felt they could control it. It turned out they were wrong, of course – the only one who has been able to out-maneuver the Clintons is Mr. Obama – and the plan Mrs. Clinton finally produced (despite all the “input” from diverse private interests) really was a blueprint for a full government takeover of healthcare, all spelled out and wrapped with a bow.  But because the private interests were powerful and confident in those days, once they figured out what the Clintons actually had in mind they were able to scuttle healthcare reform entirely.

In contrast, today the private interests have come to the table not out of strength, but out of weakness. They come not as partners in negotiation, but as vanquished foes. They come to Obama as the Carthaginians came to the Romans after the second Punic war, suing for peace, begging for terms, offering massive tribute (in this case, $2 trillion) in exchange for being permitted to eke out a meager survival, at the edge of the desert. (DrRich wonders whether the insurance companies and their friends remember the third Punic war.  Surely they must know that somewhere in Congress is another Cato the Elder, ending every speech with the words, “The insurance industry must be destroyed,” and that at some point their remaining, puny base of operation will be completely sacked, and their mission statements sown with salt.)

Second, whereas Mrs. Clinton was a major policy wonk who reveled in providing a fully-fleshed-out and exquisitely detailed set of plans for healthcare reform – thus giving her foes sufficient ammunition not only to defeat her reform plan, but also to banish the Democratic Party to the wilderness for three election cycles – Mr. Obama is not. His reform plan will be bare-bones – merely an outline, more-or-less a statement of principles. There will be nothing to attack, since there will be no details, and little will be spelled out. (Implementing the plan will be left to unelected bureaucrats and regulators, who are always happy to produce prodigious amounts of undecipherable and self-contradictory detail.) This time, at least prior to its actual implementation, critics of the reform plan will be left trying to attack a phantom.

And third, this time there is no Plan B.

In 1994, once the private interests had scuttled the Clinton healthcare plan, they immediately offered an alternative. They came to us and they said: “Citizens!  We have just now dodged a bullet! Thanks to us insurance companies, doctors, drug companies and other patriots, the frightening socialist machinations of the Clintons have been defeated, and the Evil Ones have been reduced to embracing our agenda of tax reform and welfare reform as if it were their own.  But where does this leave our healthcare system? We stand now between Scylla and Charybdis, between the spectre of socialized healthcare on one hand, and the continued profligacy of traditional fee-for-service on the other, and we cannot survive either.

“But here,” they continued, “is a third way. A painless way, an American way, based on the principles of managed care, open markets, and free enterprise. Let healthcare become a business, like any other business, and let the natural efficiencies of the marketplace find ways to cut costs and improve quality, and with minimal government intervention.”

And thus we were launched into an era of managed care run by HMOs and other similar creatures of the insurance industry. And over the past 15 years, while managed care has utterly failed to produce any of the things it promised, it has not been for a lack of trying. They indeed have tried numerous things to control spending, from the reasonable-sounding to the absurd to the frankly murderous, and despite all their strenuous efforts the healthcare system remains a morass of confusion, waste, and inefficiency, and its costs are many times what they were in 1994.

To say it another way, the private concerns, this time, have shot their wad. They are entirely bereft of ideas. They know not what to do.

And that’s why they have now fully abandoned their old allies, the Republicans (who are off somewhere – one knows not where – muttering to each other about the efficiencies of the marketplace, and wondering why nobody is listening to them). The last thing the insurance industry wants to hear today is that the burden of figuring out how to control healthcare costs belongs to them. They’ve tried everything they know and have failed, and they are desperately seeking terms for surrender.

So there is no Plan B this time. As of this week, the private interests have formally and publicly admitted they don’t have a clue. They’re throwing in with President Obama, despite the fact that they have no leverage with him whatsoever, not because they believe in his reform plans (which have not even been described in their most skeletal form), but because there is no place else for them to go.

And so, the last obstruction to healthcare reform has been removed. The path – the only path – is clear. If we fail to get comprehensive healthcare reform now, it can only be for one reason. It can only be because Mr. Obama and the Democrats, looking down that wide open road, will be unable to avoid seeing where it leads, and will decide that they do not want to be the administration or the party that finally has to begin saying the “R” word in public.

To turn away from healthcare reform now, when the way seems so clear, would be a crushing blow to them, and would likely not be politically survivable. But to go on will likely force them to begin speaking a truth – that rationing is unavoidable – whose name is more taboo than ever was the name of Yahweh. And every high priest of the ruling class knows that even hinting about healthcare rationing is political suicide.

But still, there it is. There is no Plan B.

Talk about Sylla and Charybdis.

*This blog post was originally published at The Covert Rationing Blog*

Having A Ball: Kentucky Style

I’m writing this post mostly to embarrass my girlfriend Gwen Mayes, but also because I’m mentally exhausted from preparing Grand Rounds for publication tomorrow, and thought I’d engage in some frivolity.

Gwen and her friend Scott are pictured here en route to the Kentucky Inaugural Ball in Washington, DC. Most states are hosting their own celebratory ball tonight – and Kentucky’s Bluegrass Ball won an “Editor’s Pick” from the Washington Post. It’s one of the largest and best balls, and I suppose that makes sense if one assumes that southerners do this kind of thing well (I lived in Texas for four years, so I’m allowed to joke about that).

The Bluegrass Ball has some predictable highlights, including the “Kentucky Bourbon Trail” sponsored by the Kentucky Distillers Association, and a guest list that includes everyone from Governor Steven Beshear and Senate Republican Leader Mitch McConnell to the band “Joey and the Cruisers.” What I did not expect, however, was that the caterer for the event would import “720 heads of Bibb lettuce” as part of a “Kentucky-friendly menu.” I soon learned that Bibb lettuce was first cultivated in Kentucky by Jack Bibb in the late 19th Century. Am I the only person who didn’t know this?

I’ll be attending a few events on Pennsylvania Avenue tomorrow during the inauguration day parade. Gwen and Scott will be spending the night at my place – and I can only hope that they bring me back a goodie bag filled with Kentucky goodness – especially the Bibb lettuce.

Addendum: My friends make a b-line for the Maker’s Mark booth…


And here they are horsing around:



And no, they didn’t bring me any Bibb lettuce back from the ball (dang it)… just a floral arrangement they picked up from some guy in the subway who was returning home from the Indiana Ball. Oh… and some Maker’s Mark.

Grand Rounds Edition 5:18, January 20th – Call For Submissions

Dr. Val is hosting the historic inauguration day Grand Rounds at MedPageToday. Please send your submissions to this email address: valjonesmd AT gmail dot com. Put “Grand Rounds Submission” in your email title and please use this format for the body of your email:

  1. Post title
  2. Post url
  3. Short description of the post
  4. Blog title
  5. Blog url

Although I have never done a themed Grand Rounds before, it would be terribly remiss of me not to acknowledge healthcare reform on the very inauguration day of our new President, Barack Obama. So please send me your best posts about the change you’d like to see in healthcare. If we do a really great job of this, maybe Tom Daschle will take a looksie? Don’t laugh, but DC is a small world – I share a hair stylist with Tom’s wife, Linda!

Please send me your submissions by midnight, ET, Sunday January 18th. I will include all submissions, but will give more weight to those that are about healthcare reform.

For those of you who are reading this and wondering what on earth I’m talking about – please read about Grand Rounds here. It’s the weekly summary of the best blog posts from the medical blogosphere.

My inaugural Grand Rounds will be published at MedPageToday at 8am, Tuesday, January 20th. (This link will work from that time on). I hope that we’ll reach an unprecedented number of readers on this platform.

I look forward to receiving your submissions!

Warmest Regards,

Val

P.S. Please enjoy Barbara Kivowitz’s Grand Rounds this week – it has a Sci Fi theme! The January 27th edition of Grand Rounds will be hosted by: Chronic Babe.

Ten Good Things About The U.S. Healthcare System

President-elect Obama and Secretary of HHS designate, Tom Daschle, invited concerned Americans to discuss healthcare reform in community groups across the country. My husband and I hosted one such group at our home in DC yesterday. Although we had been instructed to compile a list of compelling stories about system failures – instead we decided to be rebellious and discuss “what’s right with the healthcare system” and compile a list of best practices to submit to the change.gov website.

The event was attended by a wide range of healthcare stakeholders, including a government relations expert, FDA manager, US Marine, patient advocate, health IT specialist, transportation lobbyist, real estate lobbyist, health technology innovator, Kaiser-trained family physician, medical blogger, and EMR consultant. Here is what they thought was “right” with the healthcare system:

1.    Customer Service. Market forces drive competition for business, resulting in increased convenience and customized service. Healthcare consumerism has driven patient-centered innovations that improve quality of life. Examples include convenient walk-in clinics, online scheduling, services available in a one-stop location, and seamless transfer of health information (such as within the Kaiser Health system).

Memorable Quote: “We have a tremendous amount of choice in our system. That’s very good for patients and I hope we never lose it.”

2.    Accommodations For People With Disabilities. Kaiser Permanente was cited as an organization that takes special interest in facilitating good patient experiences for vulnerable populations and people with disabilities. For example, extra time is allotted for travel to and from the clinic, and schedules are built with flexibility to accommodate mobility impairments.

Memorable Quote: “Kaiser trains all its staff to be sensitive to people with ethnic, racial, and sexual preference differences. They learn to listen to the patient, and never assume they know what they think or feel.”

3.    Specialty Care. So long as a person has health insurance, access to the very best specialists in the world is available in a very democratic fashion to all patients. Several success stories included surgery and follow up for major multiple trauma, and congenital anomaly repair.

Memorable Quotes: “I’m only here today because of the technical skills of a U.S. surgeon who saved my life…” “I’ve traveled all over the world, and I wouldn’t want to get my medical care in any other country.”

4.    Social Media. Internet-based tools and social media platforms are leveling the communication “playing field” between providers and patients. People are discussing their care and treatment options with others like them online, as well as socializing with physicians and receiving real-time input on health questions.

Memorable Quote: “On Twitter I have I.V. access to physicians. I asked a health question and within 10 minutes I had 6 physicians answer me.”

5.    Access To Allied Health Professionals. Scheduling time with mid-level providers is easy, convenient, and effective. Patients enjoy the ability to access generalist care with nurse practitioners (for example) who provide quality care at a more relaxed pace.

Memorable Quote: “I love my nurse practitioner. She really listens to me and her schedule is much more flexible than physicians I’ve known.”

6.    Drug Development For Rare Diseases. The U.S. government offers grants, extended patents, and exclusivity to drug companies willing to develop drugs for rare diseases. This dramatically improves the quality of life for patients who would otherwise have no treatment options.

Memorable Quote: “The FDA recently approved the first drug for Pompe’s disease. Only a few hundred patients in the U.S. have the disease, and yet this life-saving medication was developed for them thanks to government incentives.”

7.    Patient Autonomy. The healthcare consumerism movement has replaced medical “paternalism” with care partnership. Patients are seen as consumers with choices and options who must take an active role in their health.

Memorable Quote: “Patient accountability is key to better health outcomes. But they need guidance and decision support… General health literacy is at a sixth grade level.”

8.    Health Education. Technology has improved health education dramatically. Patient education about their disease or condition is often facilitated by demonstration of computer-based anatomic models.

Memorable Quote: “I think that doctors are getting much better at communicating with patients in ways they can understand.”

9.    Coordination of Care. Some hospitals like the Mayo Clinic do an excellent job of coordinating care. For example, they provide each patient with photos and names of all the physicians, nurses, and specialists who are on their care team. Nurses update the patient’s schedule daily to reflect the tests and procedures anticipated and provide dignity and sense of orientation to the hospital experience.

Memorable Quote: “The Mayo Clinic has gone Facebook.”

10.    Democratization of Information & Transparency. Patients have the right to view and maintain all their medical records. They have many PHR options, and may be provided with CDs or thumb drives of their personal radiologic information to take with them to their next provider. Many doctors write their notes with the understanding that the patient will be reading them.

Memorable Quote: “One day soon, hospital stays will no longer occur in a black box. Family members and friends will be invited by the patient to view their daily schedule online, while nurses update planned procedures, events, and meetings. Family members won’t miss the opportunity to meet with the patient’s care team, because it will be on the schedule. MyChart (from EPIC) is working on making this hospital experience a reality at the Mayo Clinic soon.”

***

Thanks so much to all of you who attended. My husband will be preparing a report for the transition team shortly.

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