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Practicing Primary Care: A Lesson In Treading Water

As a primary care physician, I am becoming painfully aware of how hard it is to be good –- I mean really good — at what we do today. I would prefer to believe that it has always been so, yet I do not believe that our predecessors in the medical profession found it nearly as difficult to excel in their time as we do now.

With all of the technological and medical advances, you might ask how I could believe this to be true. Too, you might consider it pessimistic or even crazy to suggest that physicians 20, 30, or 100 years ago found it easier to practice medicine well in their time.

You could counter with numerous or obvious examples such as antibiotics, pharmaceuticals, robotic surgical procedures, or even our wondrous ability to peer inside the human body without cutting it open. You also would be correct to point out that the technological advancements of the 20th century opened the way for the medical profession to become a real science thus giving me and my colleagues the chance and knowledge to make a real difference in our patients’ lives today. Read more »

Trapped in Family Medicine Act IV: The Choice — Grow Or Pay More To Stay The Same

Introduction: As we pick up with this ongoing series, here’s a synopsis for those of you new to the story: Mrs. Doctor, a primary care physician, has been going to marriage counseling alone since here husband, Mr. Insurance, has refused her pleading to attend the sessions together. He claims she is too spoiled and is threatening to find a new partner and a happier union, not to mention to find someone new who can help take care of their children (Patient 1, Patient 2, Patient 3 …).

Previous therapy sessions went well — until the last one, when the therapist seemingly accused Mrs. Doctor of being to blame for her marriage crises. At this point in time, the therapist asked her to return explaining why she should be at fault, and this is where we pick up:

Mrs. Doctor: I’m upset with you. I don’t know if I’ll continue therapy.

Therapist: I’m sorry you feel that way. Let me get this straight, you can’t decide whether to stand up for your kids (Patient 1,2,3)  or abandon them … or whether stand up to your husband, Mr. Insurance, or abandon him … or whether to stay with therapy or not.
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Journey of the Piñata Master Part 2: The Great American Health Care Bash

As I mentioned in my post last week, Journey of a Pinata Master, The lessons of a piñata party are many and subtle, where children must acquire sufficient skill and insight to reach the highest status. Let me show you how the custom of the Mexican piñata, stuffed with candy and used to placate children, has been adopted unwittingly by the U.S. healthcare system to create the Annual American Healthcare Bash. At this gala, candy replaces money and adults represented by special interest groups fill in for children.

The American Healthcare Bash is hosted yearly by insurance companies and the government. These two organizers start asking for donations. In 2009, the piñata will be stuffed with $2.4 trillion (give or take a few billion). In 1999, the piñata held a measly $1.2 trillion. By 2019, piñata is expected to hold $4 trillion. Party planners already are worried about finding a rope strong enough to hold this massive elephant piñata (or donkey, depending on which animal you prefer to hit).

Donations arrive through taxpayers, employers and anyone willing to gain admission to the festivities. Before the party starts, insurance companies remove 20% of the money as their “set-up fee” for hosting and establish the basic game rules. During the event, they take turns controlling the rope holding the piñata.

Any American who contributed to the party, including everyone over 65, is invited to watch the spectacle as the myriad special interest groups (SIGs) take turns batting the piñata. These SIGs include ad almost infinitum: primary care doctors, nurse practitioners, radiologists, imaging specialists, laboratory services, pharmaceutical companies, durable medical suppliers, lawyers, software engineers for electronic medical records, coders, billers, patient navigators, receptionists, schedulers, nurses, billing specialists, hospital administrators, HIPPA compliance “police,” pay-for-performance analysts, the American Medical Association delegates, and hundreds of other professional organizations and credentialing specialists.

Every year, more SIGs have been invited to the gala for their turn to bash the piñata. Most thank the public for such an extravagant event, repeating the chorus, “Don’t worry what this is costing, we’re not hurting you, we’re going after the piñata.” This piñata promises more loot than any other in America.

One by one, players are blindfolded and spun in dizzying circles by the insurance companies or government. Patients start the play and then hand we doctors the bat saying, “Good luck! Give your best shot at whacking what you can from that piñata! I could care less because I’m “protected” by my insurance plan.”

Each player swings wildly, sometimes accidentally bashing the others crowding around the bobbing target. The crowd roars its approval while some SIGs scream instructions of where to aim as the batter swings away. The rope jerking increases as more skilled batters take their turn. When money pours from the breaking hull of the piñata, hordes of SIGs dive in a feeding frenzy. After decades of careful construction, the piñata has been compartmentalized so that no single player can knock out too much money at once.

As the party winds down, most SIGs have received a “fair “ amount of money, but they are angry, never satisfied with their share. Of course, there are a few masters in the crowd, who are grinning ear-to-ear.  When the party closes, the insurance companies take the piñata to another room and remove, behind closed doors, the remaining money (profit) of the day.

After counting its loot, the insurance companies emerge, announcing that it’s been another successful party, drinks all around! Then they say, “The party next year will cost only 8% more. Before you leave tonight, pay up.” Feeling threatened, taxpayers and employers reach deep into their pockets to pay for next year’s gala. Why ruin a great American tradition? If you get sick or don’t pay “your fair dues,” then hasta la vista.

As we grow up, most of us move past the need to gorge candy. Contrarily, when it comes to healthcare, few can limit how much they want to consume, nor recognize its often empty promises. Americans watch with fascinated horror at what’s happening in healthcare while remaining paralyzed to move cohesively towards change.

No matter how well intended and dedicated the doctors and nurses or how amazing the technology and medical breakthroughs to which the  “insured” have access, the unrelenting piñata party lure inevitably results in a mass psychology of “How much money can I make?”

If you, dear reader, are scared of change and continue to support the current  American healthcare piñata party, then be prepared to be beaten to a pulp. Now that you’ve paid your $20 co-pay entrance fee to the party and have emptied your wallet to the insurance company for what you believe is unlimited access to care, you have unwittingly turned yourself into the piñata.

Personally, after lots of experience and practice, I developed a healthy cynicism regarding the greed of this kind of parties.  Ten years ago, I no longer could support the American Healthcare Bash. We built a new practice where the only focus is the patient; the patient pays transparently for the time they need. This idea delivers better care, 24/7 immediate access whenever and wherever you need help at a price that is almost 50% less than the current model.  We need a lot more healthcare professionals and patients to invest in a new future of responsibility. A growing mantra is needed among patients and doctors alike, ”Do the right thing, for the right reason at the right price.” Unlimited wealth, and unlimited health are nothing but mirages, the deepest secret of all stuffed inside the piñata.

Until next week, I remain yours in primary care,

Alan Dappen, MD

Journey Of A Piñata Master

My early childhood memories hit and miss like a receding dream until four years of age when I boarded my first airplane flight. Our family landed in Mexico City to live. The experience was the first of many jolts which awakened my dreamy complaisant memory.

Within weeks I started kindergarten. That first day was filled by my ceaseless crying. Much to my relief, I had mastered the art of playing hooky by the next morning. A week later I matriculated into the American school. Scary but at least fifty percent of the day was in English. It wasn’t long before a Mexican classmate invited me to his birthday party, complete with a piñata. I was too young then to understand that a piñata holds as much in life metaphors as candy and little did I realize then that this metaphor would resurface again in my life decades later as the efforts to reform the embattled U.S. healthcare system.

Like so many things that first year in Mexico, the piñata held excitement mystery and possibility. At that first party I was an eyewitness to a mob. The instant the piñata broke open the school of piranha-like children devoured the innards so fast that I was left dejected, clutching only a little scrap given to “the gringo” by some benevolent adult.

At the next party, when it was piñata, time, I was in the mix; I dove in before the final coup de grace and caught a piece of the bat. My strategy turned upon being first one in but missing the bat, only to learn that this transferred the piñata to the one embracing almost all the candy. I was jumped, kicked, whacked, gouged, and crushed to smithereens while all those greedy hands and bodies piled on me and plied the precious treasure for my hands. Once again I emerged with tears and a few scraps.

Finally by the fourth party I’d gotten adept with the bat and with a super satisfying whack disintegrated “the Toro” to shreds. Pay dirt at last. By the time, my blindfold was off, the scrum was well underway. The school of hard knocks was one more time teaching me a lesson.

Few activities can compete with a piñata party in a child’s imagination. It offers the opportunity of unimaginable candy treasures. After years of practice and experience the master can be picked from the crowd. This child can be seen as cool, calm, and collected. They bat early, never trying to break the treasure open but enough to soften it up. Once back in the pack they make subtle repositioning moves as the batter swings in different directions blindly thrashing at the swaying and bobbing papier-mâché animal idol. At the right moment they dive into the scrum usually coming up with a lot of candy. Winners keepers losers weepers. That’s the rules.

There are many strategies at the piñata party, the imagination of greed can get the best of you when all those marbles (or candy or money) sit inside that single collective pot.
Fifty years later I cannot help but reflect that the rules and spiritual lessons gained within the piñata experience are very applicable to the US healthcare system. With thirty years of healthcare experience I remain awe struck at observing the same sets of behaviors demonstrated at children’s piñata parties.

Be you the patient, doctor, hospital, pharmaceutical company, lawyer, supplier, coder, consultant, or insurance company, each party fully play out their perfect, “what’s in it for me” expression, “Don’t worry what this is costing, we’re just attacking the piñata. Everything in the party has been fully covered. Cracking a few of heads to reach the object of my desire is just good party fun, no offense.”  We have become piñatas inside of piñatas, with of course the patient metaphorically becoming the ultimate piñata, after all the party is thrown for each and every one of us willing to pay entrance to the ever increasingly expensive party.

Next week I will start with my personal experience and then move to the global great American health care healthcare piñata gala bash. Let me get the party invitations sent out and also invite you to attend the grand gala 2009 healthcare piñata party.

I’ll let you bring the pinata to my party if I can bring mine to yours.

Until next week I remain sincerely yours in primary care,

Alan Dappen, MD

The Pronouncement: The Healthcare Debate In Nutshell

The year is 1989.  I drive cautiously along the rutted, pot-holed, brush-overgrown trail in my four drive “Suzy Trooper,’ threading through Tsavo, Kenya’s largest National Park, to one of its most remote and premier rock climbing areas, Kitcwha Tembo. Next to me sits my friend and climbing partner Iain Allan, a crusty and adventurous Kenyan who prefers the bush to civilization.

To this day, I remember exactly the moment he makes his pronouncement. Maybe it’s the lighting, or the elephant that has just blocked our road passage moments ago, or the fact that vigilance is critical to not being left stranded and risk becoming part of the food chain. On the other hand, Iain is always colorful.  “ Alan,“ he said, reminiscing about his more than twenty years of guiding foreigners on adventure safaris through Kenya. “Don’t get me wrong. Americans are great people. They are friendly, generous, and love to laugh.  But in a nutshell there’s one thing that sets Americans apart from other nationalities. Americans don’t like surprises. If just one thing happens, even a flat tire while on safari that wasn’t predicted, it ruins the rest of their day. They can’t take a surprise. If you can predict every flat tire, they might be able to adjust with a few hours warning.”

The “pronouncement” has clung to me ever since: Americans don’t like surprises. Since then I am reminded of the pronouncement frequently. Traveling in an airport offers some of the best examples. Cancelled flights are met with enraged customers screaming and accusing ticket agents as if they hold the power of “no surprises.”    I’ve seen plenty of patients leave a trail of brow-beaten staff but smile warmly once the doctor walks in the room. Most days I can feel the truth of the pronouncement as our national debate takes on tones of “Please don’t let anything bad happen to us. Please protect me, take care of me, feed me, keep me comfortable, reduce my stress, and no matter what: please no more surprises … ever!”

The no surprises stereotype might sum up the way the rest of the world sees us, but we’re blind to this. I cannot stop thinking about “the pronouncement” as it applies to health care reform. To expect fixing health care without accidents and surprises is unrealistic.  Americans might be able to adjust to all the upcoming flat tires if they are given adequate warning and have an understanding of what’s really at stake.

Here are three economic conundrums to the health care debate, and whose solutions will be rife with surprises:

  1. The U.S. spends 17% of our GDP on health care. No where else in the world even comes close to this, with 90% of other nations spending less than 10% of their GDP on healthcare. How much money is enough? How much of the economy can be allocated to healthcare and still have a functioning economy that covers housing, food, vacation, education, energy, retirement, and the security of basic needs.
  2. The amount of money spent in the U.S. on healthcare doubles every ten years and has been doing so for six consecutive decades.  If we don’t understand what drives these inflators, how are we to address solutions that curb the staggering unaffordable care heading our way?
  3. Whatever the amount of money is decided upon for healthcare in a year (and for arguments sake, let’s just say we’ll keep it at our current $2.4 trillion level for a year or two) what’s the best way to distribute this money, giving people the most options and coverage and personal choice?

I can see my friend Iain mulling these economic problems over, his face reflected by a campfire’s glow after a difficult but thrilling 5.10 climb and an unarmed descent through dense brush filled with creatures that only haunt most people’s dreams. Here sat a man who embraces danger knowing that life is nothing without surprises.  How would he handle these kinds of conundrums with Americans?

“Well,” he’d say in his Scottish-Kenyan accent, “If you can predict every flat tire, they might be able to adjust within a short while. Americans are a great people… they only need to better prepare for the surprises in life.”

“That’s too bad,” I would reflect. “It feels like Americans aren’t even close to understanding the surprises that await them in the healthcare bush.”

The terrain ahead is dangerous and riddled with surprises in all directions. There are the insurance lions, lawyers ready to strike with any misstep. Let’s not forget the elephant politicians who can stomp you to death no matter the objection. Of course there are the innocent wallowing, but vicious hippos, the cape buffalo, the hyenas, the vultures… to all the animals there is a purpose and a reason, each feeding and jealously protecting their part of the $2.2 trillion per year corpulent health care body. Lastly there are all of us patients who must journey the bush, hoping that the guide we bring might be as competent as Iain.

“Iain,” I say, “What climb should we try tomorrow? Maybe we shouldn’t make it a surprise.”

Until next week, I remain yours in primary care,

Alan Dappen, MD

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