Archive for March, 2012
I have been pretty generous in sharing my thoughts about some of the ills of our American Healthcare system, especially with regard to the barriers erected between physicians and patients. I find the various proposals now before our legislative bodies in Washington to be rather curious, even offensive. Since when does the United States of America adopt wholesale an economic solution from another country? Especially another country that is in some way otherwise riding the considerable coattails of the U.S. economy?
The “baby with the bathwater” approach in the halls of our Capitol and the editorial offices of our leading media outlets (WSJ excepted) is about as wrong-headed as you can get. What we need is an AMERICAN solution to the challenges that we presently face with the economics of healthcare in the U.S., using our present system as the foundation.
Not surprisingly, I have some thoughts!
1) Malpractice tort reform. See my thoughts in “Tort Reform = Healthcare Reform”. Effective reform will dramatically reduce the scourge of defensive medicine with its attendant costs and risks to patients. Defensive medicine represents 15-25% of all medical costs in the U.S. That’s 15-25% of $2.5 Trillion. Do the math. While we’re at it, how is it good for the country to allow the tort bar to advertise for cases? Rake the muck in the hopes of unearthing errors or imagined?
2) Tax Reform #1: Remove the tax deduction for employer-offered health insurance. Provide a 100% TAX CREDIT to the lowest 60% of wage earners for the purchase of health insurance. Provide a progressive TAX DEDUCTION for the upper 40% of wage earners.
Tax Reform #2: Remove the tax deduction for advertising as a business expense for Hospitals. If we are concerned about unnecessary increased utilization of medical resources why are we allowing advertising by hospitals? For that matter, remove the tax-exempt status of any hospital or provider that advertises. How is it appropriate to allow a hospital system to advertise to increase revenue, deduct that advertising as an expense, and still be not-for-profit? If it looks like a for-profit business, acts like a for-profit business, and sounds like a for-profit business, tax it like a for-profit business.
3) Insurance Reform #1: Reverse all of the for-profit conversions of previously not-for-profit health insurance companies. Who was the genius who thought THIS was a good idea? I don’t remember insurance premium increase that were quite so massive when all of the Blue Cross/Blue Shield plans were not-for-profit, do you? And while there were $Million execs in the non-profits I don’t recall any $10, $20, or $100 Million execs. Removing the need to answer to the stock market will create companies that will compete quite nicely with the for-profit companies without the horror of a government run system. Let the equivalent of NGO’s compete with the United Healthcares of the world.
Insurance Reform #2: Remove state-level coverage mandates and create a minimum federal set of mandates for comprehensive insurance policies. A REAL minimum. REAL medically necessary items. No Viagra or artificial insemination coverage. Allow cross-state competition for the business. Real competition always drives prices lower.
Insurance Reform #3: Allow insurance companies (Medicare and Medicaid included) to discriminate IN FAVOR OF people who make healthy lifestyle choices (eg. no nicotine, no DUI, etc.). We are all so afraid of the stick that we refuse to allow any use of the Carrot.
4) Freedom of Speech/Restraint of Trade Reform #1: Abolish, once again, direct-to-consumer pharmaceutical advertising. There was a quantum leap in the utilization of all sorts of medications immediately following the 1997 rulings that allowed DTC pharmaceutical marketing. If it is so obvious that our ever-increasing levels of spending on medical care is a threat to the very existence of our fair Union, then DTC drug marketing is a version of yelling “FIRE” in a crowded theater.
Freedom of Speech/Restraint of Trade Reform #2: Begin a return to the professionalism of yesterday by prohibiting all forms of advertising by, or for, physicians. The AMA gets a lot of criticism, most of it well-deserved in my opinion, but the court and FTC rulings that prohibited the AMA from censoring physicians who advertised was a seminal event in the de-professionalism of doctoring and medicine. Doctors and other medical advertising was, is, and always will be wrong. While we’re at it, do the same thing for the rest of the lawyers and the practice of law.
5) Public Health. Finally, and most importantly, go to the true root of whatever “Crisis” we may have here in the United States, be it a “Healthcare Crisis” or a “Healthcare Finance Crisis” or what have you. We as a people are not healthy; certainly not as healthy as we ought to be. We are not healthy because of some wrong-headed previous Public Health decisions (simple-carbohydrate based diets, abolition of school phys-ed programs, tort-fearing closures of playgrounds, etc.). We are not healthy because our ability to treat the diseases that result from poor lifestyle choices (cigarette smoking, alcohol abuse, preventable accidents, etc.) is SO GOOD that we are able to keep more and more unhealthy people alive longer and longer, paying ever more to do so along the way.
This is where true leadership can make a difference. Remember JFK and the President’s Council on Fitness? I do. 8 pull-ups in the fifth grade for me. Polio, measles, smallpox and whooping cough were once the leading killers of children in the U.S. but are now historical footnotes due to Public Health initiatives. (A pox on all the cretins advocating against childhood immunization).
We lead the world in per capita alcohol related accidents and deaths, losing young lives by the thousands each year. We have ever more increasing numbers of truly obese citizens who go on to suffer the diseases caused by that obesity, and we pay ever more for their diabetes, hypertension, strokes and heart attacks. These lifestyle choices are root causes for our increased expenditures on Healthcare, much more so than all of the targets of Beltway demagoguery like insurance company expense ratios and pharmaceutical company profit margins. A solution to this issue, more than all of numbers 1 through 4 combined or any other proposal yet floated, is the true crux of the solution to any “Crisis” we may be facing. Everything else is only there to buy time. Time to get healthy.
Pick a number; choose an age. 40. 50. 60. Anyone under that age gets “Well-care” or “Get Healthy Care” starting right now. Over that age they can have “sick care” only if they wish, but under that age if you try to be healthy you get rewarded.
There are no votes to be had in making Americans healthier. Nothing but hard work on every side of the equation. Who will stand up and do the hard work? Who will lead?
Who will have the guts to not only say that the Emperor is naked, but also drunk and fat and puffing away our economy.
Sunday musings (courting controversy)…
1) Volume. If you undertrain you may not finish; if you overtrain you may not start.
Lotta meat on that bone, especially around Games season.
2) Enabler. One who provides either implicit or explicit support of dysfunctional or harmful behavior.
I am an American physician, a specialist. Universally reviled, and nearly universally acknowledged as being at the root cause of what people regularly call our “dysfunctional healthcare system.” Funny thing, though, but my specialty includes providing ongoing care to patients with chronic eye diseases. I actually bridge the divide between specialty care (highly complex, single–organ surgery) and chronic primary care. Every day in my office I see patients with type II diabetes and other diseases that are at the very least highly influenced by lifestyle decisions.
We do not really have a healthcare system in United States, but rather a sick–care system. We actually do a pretty good job in pediatrics with a well thought out, well–established system of well–baby and well–care visits for the vast majority of children in America. Somewhere after our children leave their pediatricians in their teens the whole concept of well–care seems to disappear. No longer guided by the doctors of their youth, Americans are left to their own to make decisions about where their priorities will lie. This is certainly true of health and wellness.
There is an article on CNN.com today written by a very well spoken, highly intelligent and intuitive primary care physician from New England in which he cites a couple of examples of patients who got sicker when they decided they could not afford care for their illnesses. His approach disappoints me greatly; the appeal to the emotional is just one more way that our American sick–care system is the great enabler of our Nation’s un-well.
Think about it. We actually have the very best sick–care system on the planet. We manage to keep incredibly sickly and unwell Americans alive, and to some degree functional, in SPITE of horrific and horrible health–related decisions on the part of these individuals. Cardiac bypass surgeries and coronary artery stents. Evermore complex oral diabetic medications layered one upon the other. Heroic, simply brilliant surgical interventions to replace the joints of people who managed to double and triple the “load” they were meant to carry.
Our “health care system” not only enables our population to abuse their health and their fitness by rescuing them from their excesses, but in its present and proposed future forms it also insulates them from the responsibility of being healthy. There are certainly a minority of people who cannot afford sick care, but that number is buried by the number of people who choose to not be able to afford either health-maintenance or sick care. You only need to spend one day in a doctor’s office watching people finish a conversation on their iPhone ($499 + $100/month) about a game they watched on ESPN last night ($80/month for cable) before heading to the brewpub (smothered fries!), as they walk out to their new car ($500/month) to retrieve their iPad ($699 + $60/month) and catch a quick smoke ($5/pack, 1 pack/day), just before they complain to their physician about how hard it is to pay for their diabetes medicine.
3) DWB. Driving While Black. No matter what the story eventually turns out to be, there is very little that is good that is likely to come out of the Trayvon Martin debacle. Not for the Martin family, not for that neighborhood watch guy, and probably not for society as a whole, at least for quite a while. Why? For the simple reason that it is now 2012, we’re still having this conversation, and nobody has demanded change.
Let’s go back a bit, shall we? How about a trip to 1979 and suburban Rhode Island. I’m driving the family beater, my close friend in the passenger seat waves at a police car as we drive by on our way to the mall. My close friend, STILL my close friend, happens to be a very large Black man. You guessed it–flashing lights followed by “license and registration (no please).” Why? A version of Driving While Black.
“Come on, bingo. That’s ancient history. Things are different now.” Well, let’s move forward a bit. Dinner chez bingo sometime around the year 2000. My good friend the Rev. Mel and his beautiful wife are joining us at our house for dinner. Mel, a black Baptist minister, drives a bullet-proof Mercedes sedan. Never more than 5 mph over the speed limit. The Woodards were late for dinner. When I teased him about it Mel just shrugged his shoulders and said “DWB.” Even impeccably dressed for a dinner out, Mel was still a Black American man.
Now? I young black man in a hoodie returns from an errand, surely guilty of something until proven innocent. A non-black man approaches the youth, surely someone to be feared until proven otherwise. The fault, my friends, lies on BOTH sides of the conversation. At this late date in history it no longer matters what came first, you know? One side of the conversation needs to openly acknowledge that the vast majority of the other side does NOT participate in violent criminal activity. This part of the community needs to openly acknowledge this and aggressively teach that lesson to people of all ages. The other side of the conversation needs to openly knowledge that their ARE small parts of their community who DO engage in violent crime and to go about the hard work of isolating them as the outliers that they are and shunning them as a pox on BOTH communities.
We need to be done with the blame game. Indeed, indulging in finger-pointing at this late historical stage is also a type of enabling. By taking the easy way out, blaming this one for not fighting harder against unsupportable prejudice or pointing the finger at that one for some weak justification for criminal behavior is quite simply enabling the prejudiced and the predators to continue their pathologic behavior patterns.
NONE of us could have influenced the tragic outcome of that encounter In a random Florida neighborhood. ALL of us…Black, White, and other…have the duty and the responsibility and the ability to do the hard work necessary to prevent what STARTED it.
I’ll see you next week…
Comment #16 – Posted by: bingo at March 25, 2012 8:38 AM
Crossfit. Constantly varied functional movements performed at high intensity. At 52 years of age I am nearly the athlete I was in my twenties. How can that be, you might ask? Well, while I am not truly as athletic as I once was, I believe that I am more FIT than I ever have been. This is allowing me to participate in athletic and other physical endeavors that I really have no business thinking about at my age. What kind of athlete might I have been if I trained in my teens and twenties the way I train in my forties?
All sports came easily to me in my youth. Blessed with the genetic gifts of eye-hand coordination, speed, and quickness there was literally no sport that I tried in which I didn’t excel. Couple this with the fact that I was a very early grower (I was the center on my Jr. High JV hoops team) and I was the classic local sports prodigy for that era. In addition to pulling me out of the deep end of the athletic gene pool my parents also provided a home environment that was bathed in competition. Heck, blood might be drawn when my siblings and I tried to make the first mark in a new jar of peanut butter! I was far from special in my family; all four White kids were All-State in something, and my brother might still be the best natural athlete I’ve ever met.
The first time I “peaked” as an athlete was freshman year in High School. I didn’t know it at the time, of course, but I would never be a better High School athlete than I was that year. I had stopped growing (I was now the point guard on the High School JV hoops team), and I continued to depend solely on my natural ability. I was still skilled, fast, and quick, but I was not terribly FIT. Under-strong. Not a ton of stamina. Typical teen diet. Add in a couple of injuries and a family move and I really didn’t return to that freshman year peak until my senior year.
My next peak as an athlete came in my sophomore year in college. As a freshman Division III tailback I did well enough, but the head coach was rather underwhelmed by my size and suggested a switch to defense. Stung, I set about proving him wrong (credit that family competitive gene) and got stronger, bigger, and tried to get faster (oops…better not get THAT much bigger). For the only time in my athletic career I trained to be a better athlete, a better football player. It helped immensely that my position coach, Dick Farley, turned out to be the best coach I ever had, and that he cared more about results than size. I started a bunch of games as a sophomore and really played rather well.
I then reverted to my tried and true, relying on whatever remained of those original genetic gifts from my parents. I never got better. Not one little bit. Given the opportunity to play tons of football over the next two years, to receive the benefit of magnificent coaching and possibly become a player to remember, I coasted. In the end I was nothing but a middle of the Bell Curve DIII cornerback, an average Division III athlete. I wasn’t fit enough to do the work necessary to continue to get better and along the way I let both myself (and my teammates) and Coach Farley down.
If only I knew then what I know now. If only I had then what I have now. Bored and lonely in the gym, watching the ever outward creep of my waistline and the ever upward creep of my cholesterol, I stumbled upon Crossfit in the periodical Men’s Journal in December 2005. As a doctor who made it through Williams College, med school, and a residency I had long since learned that I wasn’t really THAT gifted. Hard work was now an intellectual and life habit, but until I discovered Crossfit I had yet to do the same thing as an athlete. Whoa! This stuff turns out to be pretty powerful medicine!
“Practice and train the major lifts: deadlift, clean, squat, presses. Master the basics of gymnastics: pull-ups, dips, push-ups, sit-ups. Bike, run, swim, and row hard and fast. Mix these elements in as many combinations as creativety will allow. Routine is the enemy. Keep workouts SHORT AND INTENSE. Keep food intake to levels that will support exercise but not body fat.”–Greg Glassman.
On January 1st, 2006 I began the Zone diet and I did my first Crossfit workout, “Angie”. Crossfitters name their benchmark workouts after women. You know…like hurricanes. 100 pull-ups, 100 sit-ups, 100 push-ups, and 100 air squats. For time. For, like, as fast as you can. Seriously. It took me 45 minutes to complete and it took me 45 minutes to get up off the floor. All 100 of the pull-ups were assisted and 80 of the push-ups were from my knees (word of warning: don’t call ‘em girlie push-ups. Most Crossfit women are scary fit and NEVER do push-ups from their knees).
I was hooked! My fitness went through the roof. My waist size shrank. My cholesterol plummeted. Three days on and one day off for 6 1/2 years and I am as fit as the day I graduated from med school at age 26. World class fitness based on workouts that typically last 20 minutes or less utilizing functional movements performed at high intensity. Competition? Yup. Me vs. me. Every day is a competition in which the opponent is yesterday’s version of Darrell, and victory is achieved if tomorrow’s version is just a little bit better than today’s.
So why now? Why at age 46? I confess that I just don’t know. I was certainly ready for Crossfit at 46, but I would probably have been ready for it at 36, too. I’m just very happy to have found it at all, frankly. Very happy to be more physically fit today than I was yesterday, with the hope that I will be able to continue to say that for years to come. Coach Glassman thinks most athletes can hope for 10 full years of improvement no matter when they start. Man, wouldn’t it be great if he was right and I still had a few years of getting better to look forward to!
Yet I do wonder, every now and again. I can’t help but wonder, what kind of athlete might I have been if I had Crossfit as a young man? If I could have been ready for Crossfit as a young athlete. When I had Dick Farley as a coach.
How many more peaks might I have reached?
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