Spurring dialogue on health care

Recently, a series of letters to the editor responded (mostly in a hostile fashion) to an op-ed published by Dr. Deane Waldman. Read the letters in their entirety (and a response by Dr. Waldman) below:

Faith in Regulation
RE: DR. J. Deane Waldman’s op-ed (“Government Drives Up Health Care Cost”): … First of all, Dr. Waldman should leave his politics out of the discussion regarding health care costs. He quotes a Heritage Foundation spokesman, and he is an adjunct scholar with the Rio Grande Foundation, both very conservative think tanks. When he quotes that 40 percent or $1 trillion in 2010 just disappears in money spent for health care, there’s no reference to where that number comes from.
I would like to quote some numbers that do have a credible source. The Centers for Disease Control and the Institute of Medicine have reported between 100,000 and 135,000 deaths annually due to hospital and doctor error. Based on those numbers, it’s hard to argue for less regulation. The free-market approach to health care hasn’t worked, so to blame government for all its cost problems is factually not true. I would recommend that Dr. Waldman read T.R. Reid’s recent book,”The Healing of America.”
On a personal note, I have over 45 years of experience as a heath care advocate and also lost two sons due to the lack of health care regulations being enforced. We don’t need less regulation.

Don’t Believe the Hype
A RECENT LETTER by Dr. J. Deane Waldman, “Government Drives Up Health Care Cost,” perpetuates many of the myths and scare tactics that have long been advanced by those against health reform and consumer protections.
The U.S. Department of Health and Human Services (recently) released its long-awaited rules that will require insurance companies to spend at least 80 percent to 85 percent of their revenue on actual patient care, a big win for consumers and patients alike, many of whom are now covered by plans that Dr. Waldman correctly notes spent as much as 40 percent of revenue on nonpatient expenses, without any accountability to their patients or the public.
Earlier this year, the Centers for Medicare & Medicaid Services noted that more than 100,000 New Mexico Medicaid recipients had received free preventive care services thanks to the Patient Protection and Affordable Care Act, and increases in health care costs were held to new 10-year lows. Up-front preventive care keeps thousands of New Mexicans out of hospital emergency rooms every year, and that saves taxpayers big money.
In the same edition of the Journal , the Career Section ran a piece highlighting the need for more health care providers to tend to the greater number of people already receiving health care. The Dec. 6 Journal ran stories highlighting the benefit to more than 18,000 students who received primary and behavioral health care from schoolbased health centers funded in part by the ACA and new provisions of the act that will help to integrate and modernize patient medical records to prevent records mix-ups and malpractice claims.
As the nation and state move forward in implementing provisions of the act, we have a responsibility to set aside divisive political rhetoric and focus on the progress New Mexico is making in creating healthy families thanks to greater access and transparency in our health care system.

The Dangers of Dogma
RE: OP-ED by Dr. J. Deane Waldman, adjunct scholar, Rio Grande Foundation:
The public policy “contributions” in the Journal from the Rio Grande Foundation are so consistently flawed and so predictably fatuous that they are cold comfort to those of us interested in civilized and informed debate.
The trouble this time, argues a Rio Grande acolyte, is that the government — always bad — has a unseemly hand on the cost of health care in this country. The villain of course is the country’s new Patient Protection and Affordable Care Act —“Obamacare” — and the crime is the desultory effect of policy intervention on the free-market cost of health care services. The real problem I would argue is that the “free-market” libertarian apologists of the Rio Grande variety are simply unwilling or unable to think about “us” in the plural in any constructive way. Any common and legitimate goals we might have as a society must pass their inane free market test. If the country were being ravished by a plague killing everything it its path, should we, the people, the government, mount a coordinated and concerted intervention? No, they would have to argue — to be consistent — let the free market figure it out. Is there any point in having any constructive ideas about the direction of the country and the health and welfare and future of its citizens? Not really; the free market will figure it all out!
Our common purse — government resources — fields a military, explores space, helps build highways and, yes, invented the Internet. In the same way, our government is in a unique and powerful position to establish rules for the private sector that bend the cost curve on health care and provide a level of coverage available to almost all citizens of the developed world except those in the United States. A stopped clock is right twice a day, but cross Rio Grande off your mustread list: The free market tooth fairy clouds their thinking about even the most basic human needs.
DOUG BYERS Albuquerque

Here is Dr. Waldman’s response:

Healthcare Dialogue, At Last! Thank You.

Deane Waldman MD-MBA is the author of “Uproot U.S. Healthcare.”

Thank you, Albuquerque Journal. Thank you, people. We have taken a first, admittedly tiny, step toward actually fixing healthcare in this country. That first step is discussion, dialogue, discourse, debate, and certainly difference.

In the Journal of 12/4/11, I wrote about how the costs of healthcare were in, not “out of,” control. I wrote that the government was the controller as well as biggest consumer of our healthcare dollars rather than We The Patients and the people who provide health care.

Obviously, people responded to that article. I write obviously because the Journal printed three responses on 12/17/11 probably out of a much larger number. Though the comments are opposed to what I wrote, I deeply appreciate them. As I have written repeatedly in books, articles, and online, the necessary first step to fixing healthcare is people talking with other people.

In keeping with the concept of dialogue, let me respond to the responders.

The Centers for Disease Control and the Institute of Medicine (IOM) are credible sources of data. But so are the Cato Institute as well as the Heritage and Rio Grande Foundations. Just because one may tend toward your political persuasion and another leans in the opposite direction is unimportant. What matters is the validity of data and correctness of conclusions.

The IOM estimated that 98,000 or more Americans die avoidably during medical treatment annually. This is, of course, unacceptable. Unfortunately, the writer, like Samuelson in his “out of control” costs article, leaps directly from symptom identification to treatment, urging additional government regulation.

In the medical world, this is called malpractice. You must first diagnose the cause of the patient’s illness before recommending therapy. WHY are people dying needlessly? Determine that, with evidence. Treat it.

One writer reported that his two sons died from lack of regulation. I would love to see the evidence proving this assertion. Further, I would welcome hard evidence that regulations actually protect us, and that such protection is worth the expense.

My evidence to the contrary includes the increased error rate due to information security regulations, the successful infection checklist from Michigan that was banned for not following NIH guidelines, and my personal experience of being “out of compliance.”

Every few years, the Joint Commission (On Accreditation of Hospitals) performs a review to assure regulatory compliance, presumably to confirm that We The Patients are being protected. Do they check patient outcomes? Do they suggest ways to improve such outcomes? Several years ago, I was found “out of compliance.”

What was I doing wrong that was harming patients? Did I do unnecessary, risky procedures? Was I doing catheterizations improperly? Were my diagoses consistently wrong? Did I operate while intoxicated? I was out of compliance – seriously, I couldn’t make this up – for: a) having books too tall in my office, and b) using a doorstop. Is that how regulations the patients? Is that a wise use of our healthcare dollars?

I did not write that insurance plans spend 40% of their dollars on non-patient expenses. I do not know how much money insurance companies use for administration and keep as profit. That is closely held, proprietary information. I only observe that the highest paid CEO in America in 2010 was the head of UnitedHealth Group, receiving $101.96 million in direct compensation alone, not counting other benefits. You do the math.

The 40% of healthcare dollars “not going to health care” that I reported was a simple calculation that anyone can do. Add up, as I did, all the money going to anyone who cares for a patient whether by service or by producing a product (wheelchairs, pills, apnea monitors, etc.). Subtract that total from the amount published by the GAO that the U.S. spends every year on healthcare. The difference is 40%.

Of course, anything that gets people preventative or earlier sickness care, and puts them in doctors’ offices or their homes rather than ERs is good. It makes people healthier (less sick), and it costs less both short term and in the long run. But how can you say that the PPAHCA provides “free care” when it is slated to cut Medicare reimbursements to physicians – and therefore patient services – by 27%, not even the 21% I previously cited?

The basic point of my 12/4/11 article is that PPAHCA steals money from health care, the service, and gives it to healthcare, the system. Can anyone show me evidence that it does the opposite? If implemented, PPAHCA hurts both We The Patients and our nation.

Another responder to my 12/4/11 repeatedly derided the “free market.” I do not care about passing or failing some litmus test as a free marketer. I am only interested in results, specifically a healthier America and healthier Americans. Any system that totally disconnects the consumer from his or her money for consumption fails. Look at what is happening in Canada, Great Britain, Greece, Italy, and Spain. The reason I want some free market forces, some reconnection, is this. Capitalism and market forces have been proven to produce the best for the most at the least cost, instead of an equal sharing of the misery, to paraphrase Winston Churchill, Margaret Thatcher and others.

I welcome a continuation of this dialogue. I implore others to speak up, not only here, but at town hall meetings such as the one sponsored by the Rio Grande Foundation on December 8, 2011. Only when We The Patients in our hundreds of millions, communicate, argue, debate, and finally get to some form of consensus on basic principles for healthcare, only then can we begin to fix our sick system.

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3 Replies to “Spurring dialogue on health care”

  1. “Arm chair economists” vs MD/MBA and Expert in Health Care Economics

    I have read with amusement the letters to the editor in today’s (12/17/2011) Albuquerque Journal criticizing Dr. J. Deane Waldman’s recent editorial regarding out of control health care costs and the government’s role in regulating and/or contributing to those costs. It is interesting that all three letters published were all critical of Dr. Waldman’s analysis with no counter opposing view(s) supporting his analysis. I don’t know if that means there were no letters to support Dr. Waldman or if the Journal simply chose not to include any letters that supported his views.

    Regardless if there was any supportive letters sent to the editor, it is both interesting and amusing to see three non-medical (and assuming, non-health care economics) professionals—unless one counts “45 years experience as a health care advocate” as qualifying as a health care professional—trying to rebut the thoughtful analysis of not only a practicing physician who has practiced for more than 2 decades within our “sick system”, but is also an MBA who is a published author and expert in healthcare economics and reform.

    It is obvious from the reading of all three letters that the basis of their rebuttal is not based on any real facts or data from scholarly journals in medicine or economics, but rather simply on personal political ideology and opinion. All three letter writers obviously espouse a more liberal “more government is better” philosophy towards healthcare—vis-à-vis “Obamacare”– and two of the letter writers ignominiously attempt to discredit Dr. Waldman’s analysis as merely the musings or political ranting of just another ill-informed or unenlightened “conservative”.

    Regarding the first letter by Mr. Richard Valdez, he somehow manages to shift the argument that more government regulation is more or less cost efficient based on the merits—or lack of—of governmental bureaucratic efficiency , instead arguing for the benefits of more government regulation in healthcare in order to improve patient safety. In other words, he is trying to compare apples to apples, but using oranges as an example. On top of that, he insinuates that Dr. Waldman just magically pulls his data (of 40% of health care expenditures not going to pay for direct patient care) out of the air if not from a “conservative think tank” while offering his own simple statistic from the CDC and Institute of Medicine (which by the way is a liberal think tank) of “100,000 to 135,000 deaths annually due to doctor and/or hospital error”. Now, did I miss something? I thought we were discussing money and bureaucratic efficiency/inefficiency here and not the number of potentially preventable patient deaths per year attributable to medical errors. What does one have to do with the other? I’m deeply sorry that he has lost two sons, but his argument that more government spending or regulations would have saved them may or may not be true, but have absolutely nothing to do with the argument that the government can or cannot be more efficient in managing healthcare!

    While this letter is meant to offer a critique of the letters criticizing Dr. Waldman’s analysis and not a separate analysis of how we can best prevent medical errors in healthcare or what the government’s best role is in preventing medical errors, I do want to point out—using Mr. Valdez’ own statistics—how easy it is to pick and choose random statistics disingenuously to support one side or another of an argument. While Mr. Valdez correctly contends that there are anywhere from 100,000 to 135,000 (actual range is 85,000 to 195,000) deaths annually attributable to doctor and/or hospital errors, he conveniently fails to indicate that number one, these are classified as “potentially preventable deaths” and number two, that these potentially preventable deaths represent an extremely small fraction (0.00005%–using the higher number of 200,000) of the nearly 1 billion (995 million) doctors visits, outpatient clinic visits, ER visits, and hospitalizations (CDC data) seen each year! You don’t have to be a “Black Belt” in Six Sigma –an extremely rigorous business ideal advocating for near perfection or 99.99966% error free processes—to see that in medicine, we get pretty damn close! Now as a physician and a father– and a healthcare consumer– I understand that we are talking about human lives here and not the manufacturing of ball bearings and that even 1 preventable death due to medical error is tragic and regrettable, but from the dawn of civilization, we have never been, currently are not, and never will be perfect in medicine or in any other human endeavor!

    Mr. Raymond Schall and Mr. Byers both just simply spout standard democratic party line demagoguery in their justification for and defense of “Obamacare” and increased government involvement in one of the most personal aspects of our lives without providing any real or objective data or logic to buttress their criticism of Dr. Waldmam’s analysis. Mr. Schall tries to also pick and choose some “statistics” to bolster his support of “Obamacare” by citing that the “Health and Human Services recently released their long awaited rules requiring insurance companies to spend at least 80 to 85 percent of their revenue on actual patient care. What he failed to mention is that in the United States, most private insurance companies spend about 6 to 11percent of revenues on “administrative costs” and 89 to 94% on “patient care costs” (multiple sources). He also did not mention that from at least 2000 to 2010, Medicare consistently has spent 19 to 31% more on true “administrative costs” than private insurance companies. He also tries to tout the benefits of “Obamacare” by stating that “more than 100,000” New Mexicans have “received free preventative health care” and “more than 18,000 students have received primary and behavioral healthcare” because of “Obamacare”.

    Now Mr. Schall obviously has never heard of or does not believe in the 1st principle of economics which basically states “there is no such thing as a free lunch”. He uses the word “free” as if “the free market tooth fairy”—to borrow a trite little phrase from Mr. Byers (the 3rd letter writer)—suddenly dropped the money into the government coffers to pay for the “free care”! Excuse me, but just because the patients received “free” or discounted health care doesn’t at all mean that it was “free”—somebody (you and I—and not the tooth fairy) in the form of increased taxes and or both increased premiums has to pay for that “free health care”! Beyond that, the medical providers providing the “free care” do so at a deeply discounted government mandated rate that often is below the amount required to sustain a viable practice!

    Finally, Mr. Doug Byer’s letter is nothing more than old and tired progressive-socialist and “new” OWS dogma lamenting the evils of capitalism and free markets thinly—as well as feebly–disguised as an attempt in intellectual discourse.
    I conclude my critique of the letters to the editor with some rather interesting “statistics” to ponder:

    1. There are approximately 1800 pages each in both Harrison’s textbook of Medicine and the American College of Surgeons textbook of Surgery which could be considered the “bibles” of Western Medicine and Surgery and which represent the collection of at least 3000 years of medical and surgical science and knowledge. This compares to 1000 pages in the Patient Protection and Affordable Act (aka “Obamacare”), 670 pages in the HIPPA regulations, and over 132, 000 pages of Medicare rules and regulations collected over the last few decades (this does not include the various state and local rules and regulations regarding the practice of medicine in States and local localities)!

    2. There are approximately 650,000 practicing physicians and surgeons in the United States and it is estimated that for every physician, there is 2 to 5 or (1.2 to 3.25 million) “non-medical administrative” workers (most of them Federal and State employees) per doctor “administering healthcare”!
    3. The Medicare Trustees have projected that Medicare (which administers to approximately 30.5 million Americans) will be bankrupt by 2024 at current spending projections and somehow we want to expand that government bureaucratic behemoth to cover 10 times that much? This is what a “real” doctor in health care economics has to say about that:
    “Contrary to the claims of public plan advocates, moving millions of Americans from private insurance to a Medicare-like program will result in program administrative costs that are higher per person and higher, not lower, for the nation as a whole.”
    Robert A. Book, Ph.D., is Senior Research Fellow in Health Economics in the Center for Data Analysis at The Heritage Foundation

    John R. Vigil, MD

    Dr. Vigil has a blog titled “What’s Wrong With American Healthcare Today; The Musings of a Working Doc” and has been a practicing physician and surgeon for over 20 years. His interests in medicine are healthcare economics, improving healthcare delivery, and history of medicine and surgery. He has completed 1 year towards his Master’s degree in Business Administration at the Anderson School of Management, University of New Mexico.

  2. As a retired medical professional (DDS) I applaud both doctors for their lucid, trenchant deconstruction of the three letters to the Journal editor. Dialogue of this high quality is sorely needed and little appreciated by the general public.

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