Category Archives: Uncategorized

Revolution or Evolution

I resurrected this old blog post because it reflects some of the most basic and fundamental issues that were not addressed by the ACA. It is as current today as in 2008. Changes in health technology, consumer-facing health tools, payment reform and Meaningful Use have not moved the needle on establishing a unified view on the the nature and purpose of health care systems in general.


Call me a skeptic, but this health care system (which does not serve the majority of its stakeholders) is not likely to change overnight, even (especially) if Obama wins the election. What we have in the US is an undesigned, organic, chaotic system which accomplishes exactly what it is designed to accomplish. Problem is, everybody thinks it is designed to do something different and the result is incoherent.

Some treat health care as an entitlement. It is the right thing to do because nobody should ever go without access to care in the face of illness. Illness is frightening, as are many other things in the world. But fear of getting sick is about as good a justification for universal health care as universal access to… say, attorneys. It may be a good thing to do, but I would rather push for universal access to information.

Many physicians see the health care system as a vehicle for the intellectual challenges and exercises in skill required of the practice of medicine. As an exercise in meritocracy, health care should be more available to those best able to pay for it. There has always been and will always be value in having uncommon skill or knowledge. I firmly believe that this drive, rather than the profit motive, is what pushes most physicians to specialize, sub-specialize and constantly and marvelously push back the limits of what can be done with the human body.

Health systems are also an opportunity to find a margin. Yes, health care is a business and in America, profit is not a dirty word.

Health care is also as “issue” for politicians, and to the extent that it affects voters, it influences the government agenda. It represents a way to get a vote.

Health care can be seen as a public health measure, which I tend to do. This suggests that those interventions that are most likely to help the health of populations (as distinct from the health of individuals) should get the most resources. With all due apologies to my sub-specialty colleagues,who are critical to our health care infrastructure from many perspective, it is here that primary care wins out hands down.

In fact, the broader the definition of health, the less medical it becomes. Securing water, adequate shelter, safe employment, reliable food sources, traffic safety and basic literacy are health issues that hardly fit into our usual conception of health care or the current reform debate. Immunizations, prenatal care and primary care are the most cost-effective things the medical world has to offer. PAHO and WHO publish guides for policy makers.

A health system like ours is at cross-purposes. Many advocate a total overhaul but that’s not how change happens. Incremental change is more likely. Even if we were to reach some sort of tipping point in technology, or delivery, or insurance we will not likely see a complete change in a high resource service sector. Despite the complexity of the health system, care is still delivered one-on-one. All other discussions remain MBA-speak appropriate for the Harvard Business Review and little else.

Don’t get me wrong, I like what I see in the health reform world. I like Dr. Val. I like Steve Case for that matter. I think what they are doing in consumer-driven health care is valuable. Jay Parkinson sounds like a smart guy and I might even ask him what he thinks about spreading his model to rural areas. I believe that the Future of Family Medicine project has enormous potential for change as evidenced by the TransforMED project and the rising popularity of the medical homes concept. PHR‘s have potential. RHIO‘s even more.

But none of these ideas are sufficiently transformative to represent the answer to a broken health system. Together, they represent a significant change in direction that incrementally may have an outsize impact.

The single notion that could have the greatest effect is the one that says we cannot and should not provide for every possible health benefit under the sun.

Rationing by cost (a barrier to access) is more acceptable than rationing by mandate, regulation, insurance company ruling or queuing. No rationing does not exist in any industry.

This means we must prioritize the things we cover. We make decisions all the time about what is covered and what is not covered, but we currently decide based on politics; that is to say the sum total of influence exerted by stakeholders and lobbies.

Frankly, it’s not a bad way to do it; I don’t believe in central planning. Look at Canada. But a better way to do it is follow the data. Otherwise every right wing crackpot and left wing entitlement-creator will have outsize say according to the way the political winds blow. Right now, we have two nutty ideas floating around: one way is expanding health care coverage under government tutelage and the other is giving tax credits to poor people to buy health insurance (source: Pikalaina). As far as I’m concerned, government should only guide and create an environment for market forces to accomplish common goals (in this case, health.) Expanding government programs is not the way to do it. Tax credits for poor people are ridiculous; I can’t get my poor patients to spend on bus fare if there is no IMMEDIATE benefit.

McCain is also promoting an idea to allow insurance companies to compete across state lines. Bob Vineyard at Insureblog seems to feel it won’t work because of differing state mandates (the analogy is with credit card companies). In other words, states are already making choices about which benefits are to be covered. This may be viewed as rationing, or alternatively, choosing which parts of health care to subsidize. In fact, I prefer the subsidy position, because it puts us on more firm moral ground. If we chose to subsidize any industry, we should do it on the basis of data and a specific goal in mind. A utilitarian like me will view government’s responsibility as creating the greatest common good i.e. the most wellbeing. This merges nicely with the broader definitions of health.

What I like about the McCain idea is that it represents incremental change. To address Vineyard’s correctly pointing out that state mandates represent a serious obstacle, they are not insurmountable. A federal rule for companies selling insurance across state lines could be that they meet or exceed the benefits coverage of most states. These policies will be more expensive than policies sold in low-mandate states, but provide useful alternatives for those willing to pay. They will represent real competition in high mandate states, which are sufficiently populous to get people asking questions. There are other legislative and regulatory hurdles to get over, but ideas should not be discarded before a full and public airing.

Transparency in the insurance industry and in hospital pricing, expanding coverage for the uninsured and under-insured, a more flexible tax code to allow for the purchase of alternative insurance products, increasing adoption of IT and maximization of its potential in measuring and affecting quality, aggressive changes in models of care delivery and defining different levels of coverage according to health impact analysis are all a small part of the solution. Overall, there is a tremendous amount of value yet to be unlocked in the US medical system, but tearing a system apart to rebuild it from the ground is not a good option. Revolutions tend to be more destructive than creative.

Cost effectiveness of well child visits

We published this back in 2008 on the old blog. It remains germane to the economics of primary care and I updated it with a link to The Incidental Economist.


Immunizations are simply the best and most cost-effective intervention ever conceived by the science of medicine. They are so important that health care providers have toyed with various techniques to improve immunization rates. For example, my current facility has a full-time immunization nurse who can give missing vaccines to children following a sick visit (as long as they don’t have a fever.)

The principle of vaccinating when you got ’em in the clinic is common in many developing countries and under-served areas, since you never know when you will see these children again.

Now the practice is being questioned. According to an article in Pediatrics, some parents don’t bring their children back for well visits. The well-child visit includes a brief developmental assessment, physical examination and anticipatory guidance. These aspects of the visit have great value, especially for the young, low-income mothers who are the most likely to conflate a well visit with a shot.

As a clinician, I understand the value of well child visits, but my public health degree must question the data. There is insufficient evidence to support annual adult examinations. Studies with children are naturally more likely to yield a benefit, but I just haven’t seen them. After all the well-child visit schedule is tied to… you guessed it, immunizations.

It’s good to know that there is documentation of the downside of opportunistic immunization (which has been our experience). I am not sure it matters in the big picture. After all, one of the few things on which health economists agree is that prevention usually doesn’t pay off.

Health Risk and Pleasure

I thought I would post this one from The Physician Executive because Val was once my favorite internet buddy. My Canadian ex-compatriate is now remarried and has moved to South Carolina. But one thing has not changed: the timeless notion that people somehow view healthcare as a way to dodge the consequences of overindulging their little pleasures. In this case we are talking about something relatively innocent: unpasteurized dairy consumption. Our health officer in Clark County gets upset every time he hears about another place selling raw milk in Clark County. The latest I found was Camas Produce selling raw goat’s milk.

It’s easy to condemn the practice of consuming raw dairy on its scientific basis. Trouble is I love artisanal French cheeses. Many are raw and were outlawed int he US at the time this post was written in 2007. I am a happy camper now that I can get unpasteurized cheese. I hope Dr. Melnick will forgive me this one indulgence.


Dr. Val at the Voice of Reason posted an article on the hazards of raw milk. She grew up on a dairy farm, so her observations are particularly cogent. The article raised two questions in my mind.

First, our clinic’s practice is heavily Latino, dominated by Salvadoreans who have a tradition of consuming raw milk products. In fact, Salvadoreans consider yogurt made from raw milk one of the healthiest foods for young infants. My patients tell me it is usually introduced at around two or three months of age.

Of course, this goes against the usual recommendations for baby feeding in the US, which appears to me to be based on bowel maturity and propensity for allergies, as much as on healthy nutrition. There have been sporadic cases of bovine mycobacteria amongst Hispanic infants in our area, which is a stone’s throw and a ferry ride across the Potomac from Dr. Val’s stomping grounds (so much for anonymous blogs, eh?)

My classic and rigorous medical training causes me to carefully counsel my patients against the consumption of anything other than breast milk and formula for the first four months and to avoid raw milk products until they are old enough to choose for themselves. My cultural sensitivity makes me wonder if this is truly appropriate.

Yogurt, perhaps reserved for later infancy, is probably a great source of nutrition to have become an important staple in El Salvador. Culture is important to everyone who has one, and food and child-rearing are important aspects of culture. The documented number of infections in our County was 4 in 2005. Is that enough to intrude on culture and tradition, or can we just remain sensitive to the fact that these children are at risk an intervene early? I’ve never had to treat an infant with cow tuberculosis in their gut, but I wonder… I just wonder…

The second thought that came to my mind is about the French! No I’m not getting political… I just like French cheese. One of my favorites is Camembert from Normandy made from raw milk. Perhaps there is something in the process of making cheese that I am missing, but raw milk cheeses taste better and have been really hard to find because of the Department of Agriculture’s import restrictions. I just found a really smelly cheese store nearby and I’m in heaven. The first thing I asked is if they had raw cow’s milk cheese and the guy behind the counter smiled and nodded knowingly. He probably figures me for a connoisseur for asking!

Raw milk products have inherent hazards, but this isn’t like eating a puffer fish prepared by a novice sushi chef.

Just wondering…

Disruptive Innovation

This is based on an old post from The Physician Executive when I first started thinking about the place of disruptive innovation in health care delivery.


The problem with disruptive innovation in health care is thinking twice about how it applies.

A couple of precepts before we begin, just so we’re all on the same page, or at least the same library:
1) First the technology can exist for a long time before it is adopted, if at all. It is in the application that an innovation potentially becomes disruptive.
2) Adoption is likely to come from smaller players as new technologies are frequently overlooked by the big players.
3) The innovation is not disruptive to the consumer. It is disruptive to other producers. The consumer adopts it because it is simpler and cheaper than the alternative.

In my world, the innovation will come from changes in the way health care is delivered, not about a sexy new scanner or robotic procedure or even a new iPad app for diabetics. And here, observations about how slowly such innovations are taken up become pertinent.

I would argue against big business. Lately, consolidation has caused health care to be delivered out of monolithic medical systems incorporating primary care, specialty, allied health (physical therapy, audiology, optometry among others) and imaging services. This creates a few problems:

1. Like big government, big business generates an entrenched bureaucracy that is resistant to change, difficult to navigate and primarily interested in perpetuating itself.

2. Incentives are skewed to generate more testing and services. Primary care, when properly delivered, reduces downstream costs to the system, meaning less revenue for the organization.

3. There is less choice (see availability of reproductive services in areas dominated by large Catholic health systems) and the cost advantages of scale initially required to reap the benefits of the technology deployed are rarely manifest.

Carving primary care out of the health care delivery system and providing a special place for it with better revenue, greater legal protection (e.g. tort reform, voiding non-competes) and subsidizing an infrastructure to allow small, personal, relationship-based practices would be a tectonic shift on how we think about health care.  Now that would be disruptive; and just as the iPhone disrupted the PC market, it is only primary care that can disrupt the medical tech (specialty/referral/imaging) sector.

Maybe this is why Clayton Christensen believes health care is ripe for disruptive innovation, although the comments confirm to me that he has not yet found the right disruptions. It will be up to people like Dave Chase, Rob Lamberts and Brian Forrest to figure it out. I could include others, but why take sides?

What the Heck is Cultural Competence?

I stumbled across this old post about Washington trying to pass a bill mandating continuing education for physicians on cultural competence. They just did it again in the legislative session that ended. Again the bill died, but not the one mandating education on suicide prevention.

Suicide prevention is a wonderful thing, but I will be obligated to spend six hours of my valuable time learning about something I bet I do better than 99% of the doctors in this state. I’m not being cocky, it’s just that we have very few psychiatrists around and I have had to upgrade my psychiatric, pharmacology and counselling skills.

The sad part is that it will not help suicide prevention because CME is superbly badly suited to the skill required. So here is the old post.


Washington State has chosen to address the cultural competency of their physicians and providers.

While this is laudable in purpose, an effort to assure cultural competence is difficult to implement well. On the face of it, additional training seems the logical response to a deficit in cultural competence. Unfortunately, continuing medical education and training has never been demonstrated to effectively change the practice patterns of physicians, so there is no reason to believe it will work here.

One could try to increase the diversity of the physician supply, but my experience is that whereas this may improve the satisfaction of people with similar ethnic and cultural backgrounds, it does not address the competence of physicians dealing with a diverse group of patients. Foreigners of any given ethnicity are no better able to deal with other ethnicities than a plain vanilla white American boy.

Moreover, the way cultural competence is presented can be dangerous, the way many well-intentioned efforts succumb to the law of unintended consequences. For example I recently received a brochure from The Joint Commission (aka JCAHO) which represents different ethnic groups and their usual beliefs and behaviors about illness.

Many of the ‘facts’ presented are truisms and platitudes that only hold for some people in any given population. Not every Hmong rubs coins on their childrens’ backs and not every Latina mother thinks about cold and hot illnesses. These beliefs are typical of ordinary people and thus much more dramatically influenced by socio-economic status within the culture that by the culture itself. It is tantamount to calling an Asian smart or an African athletic. Whether or not the statement hold true in the aggregate, the seed of prejudice (i.e. pre-judging) lies in assuming that the person in front of you shares those attributes.

Perhaps there is a different way to assure cultural competence, but also to address the underlying issues for poor communication between physicians and patients. Physicians are taught interpersonal and communication skills in medical school and residency, but the training is uneven and inconsistent between programs. To deal with every person on a psychosocial continuum is to see them as a unique collection of ethnic, cultural, social, family personal, biological and genetically determined experiences that need to be peeled away layer by layer without assumption, judgment or bias. Culture rightly become a focus, but only of one of several factors which shape the interaction.

In the cognitive specialties, like the primary care specialties, the ability to provide satisfactory care without excessive investigation is the key to assuring low-cost, high-quality health outcomes.

I would propose we completely and utterly abandon cultural competence (by the way, I am convinced Washington State is using “competency” in a grammatically incorrect way) as the framework for how we approach patients and replace with a broader psychosocially defined “communication competence concept.” These can be taught through the current channels with an IOM-driven effort to influence curricula via ACGME and the AAMC. In other words, use current channels to support a broad communication-skills agenda rather than a narrow-focus of cultural competence.

Some resources can be found at HRSA, Joint Commission (aka JCAHO) and the ANM.

Immigration and Health Care Costs

Impressions from a cross-country road trip dominates this
Physician Executive post from 2008. The cultural diversity of the country made a big impression on me. It is ironic that while we argue today about Immigration Reform, the pressure from immigration has been dissipated by new economic realities. Net migration from Mexico is now negative. I suspect it is only a matter of time before xenophobia rears its ugly head again in the healthcare debates.


In my drive across the country, I encountered many languages. Coming from a polyglot city like DC, it is easy to be jaded about the American heartland and consider fairly white-bread. This is why it struck me that I encountered so many cultures along the way. I could have said that there were more non-English culture Americans along the way, but then I would be grandstanding.

I did run into a family of Greeks from Turkey along the way, an almost vanished cultural subgroup. Mostly I found myself conversing in my broken Spanish. First was a family from Cuba and we met in the St. Louis arch. Of course the dominant group was Mexican-American, who manned convenience stores, restaurants and hotels the entire length of the country, even in the most white bread areas. I even saw a young black man cleaning a hotel room, a truly unaccustomed site in this country over the last decade, but it was at a National Park, where reasonably affluent young adults work hard in exchange for the adventure of their lives.

All these impressions came on the heels of a radio talking-head saying something to the effect that the trouble with this country was the extent of illegal immigration. He was saying that people seemed to think it was OK to break the law or to simply ignore it in such unprecedented numbers.

So, that would mean that all laws must be vigorously enforced at all times. I’m glad this guy isn’t in charge of the highway administration; I would have been in trouble with speeding especially in some abandoned stretches of road in the West. But the level of policing required to eliminate all speeding in the country would be onerous, certainly it would be cost-prohibitive. Before the ACLU lost its way when the real issues gradually disappeared, they would have gently reminded us that not all laws are meant to be enforced severely given the risk that we could begin to look like a police state; a deplorable condition to be avoided at all costs. Indeed the fathers of this country did proclaim their liberty, or their lives!

If a law requires such severe and absurd efforts like building a wall across a natural resource like the Rio Grande, then I would consider the law worthy of re-evaluation. A law of the land is not a natural law. It is not the Law of Evolution, it is not a Law of God handed down to Moses, or elucidated by Mohammed or revealed by Christ. This country’s laws reflect intelligent people’s best bet on how to secure the greater good.

Our immigration laws are not only ineffectual; they are economically and socially counter-productive.

I caught a CSPAN rerun of Chris Matthews plugging his new book and he suggested that he had a problem with providing government documents to people who were not supposed to be here, i.e. making someone look like they had a status or legitimacy they did not have. That, I can understand. His position reflects serious thinking about how to approach the problem of rapid, undocumented immigration. But stopping immigration altogether is a boneheaded concept. Stopping illegal immigration is unlikely, given the strength of the forces behind migration. In fact, it is the complexity of human migration decisions that makes draconian immigration enforcement so stupid.

It is also economically counter-productive since I am convinced that labor is an asset for any country and does not represent a net burden in services. Some services relate to infrastructure that already exists and incremental increases are not necessarily harmful. Other services such as health care have raised some people’s hackles.

Those people who are up in arms over health care costs to immigrants need to come off it! Immigrants, especially illegals are mostly young, fit and hard-working. They do not come with the express purpose of seeking free health care for themselves or their families, although that may play into their needs after several years if their parents fall ill. There are numerous indications that immigrants, and especially illegals, use less health care and are more likely to pay for it than America’s own native poor. (By native, I mean born in the USA.)

The major burden in most areas is a fertility rate that approaches third world levels, but we’re too busy preaching the ineffectual dogma of abstinence to do anything about it (but that’s another post.) If anyone bothered to do a detailed economic accounting of the costs and benefits, I suspect it would quickly become clear that even illegal immigration is of net economic benefit to this country. Issues related to national security are just more fear-mongering to which I have become inured.

In construction and agriculture alone, this work force represents the ultimate in flexible, mobile work force to do labor of a kind no American would accept to do for any wage. To get native born-American to take up the back-breaking toil which is manual farm labor, we would all be looking at $8 tomatoes and a $20 head of cabbage.

If the problem is that there are too many immigrants, then I say it is the same old xenophobia that has affected people since time immemorial; a mean-spirited, deeply-rooted human fear of all that is unfamiliar. If the problem is only that such immigration is illegal, then I say change the laws. They are too impractical and poorly thought out for my liking. There are better and more intelligent ways to deal with a big incentive for economic migration from our southern neighbors.

The fear of health care costs related to immigration is just one more ideological bone from the political demagogues.

Response to Michael Cannon

More on Cannon and the USA Today article from 2007.

I have had trouble responding to Michael Cannon. I knew when I first read his response to my critique of his USA Today Op-Ed (that’s a mouthful to follow) that more should be said. He spent most of his time defending incorrect referencing in his Op-Ed, but there was something more. The more I read, the more I perceived a purposeful selection of data in support of an existing position. I am more familiar with the scientific method which requires the writer to follow the data, including contradictory evidence. Mr. Cannon comes from an ideological perspective to which I cannot relate. Perhaps no response is required for ideologues. After all, what is the purpose of the Cato Institute but to purvey a particular ideology?

I have a libertarian streak, but I am no libertarian. These ideas serve as a reminder that there are limits to what government can and should do. There are limitations to the financial resources of any society. I do not believe that there should be a single payer or that everyone is entitled to every possible medical intervention. But as I dig deeper, my understanding is growing of the ideology which shares these principles.

First let me direct some comments directly to Michael’s defense of the USA Today Op-Ed:

  1. To minimize the number of uninsured is to miss the point that there are vulnerable people in society who need some assistance. The government has a role in improving the quality of life of its citizens by supporting education, defense, law and order, health care and probably other areas as well. To believe the government has no role whatsoever is false, intellectually on the fringe and historically on the road to revolution.
  2. To suggest that all people covered by Medicaid would be better off with private insurance is as ignorant of the lives of the poor as Mariah Carey talking about poor starving kids and flies and death and stuff. Crowd-out as Michael Cannon describes is another name for cherry-picking. To force low-income individuals who are most likely to cost insurers more money is to keep private insurance more profitable for the insurers.
  3. Most medical care is not cost-effective, as measured by macro-level indicators. Since leaving Canada I have learned that no country ever became great by trying to be cost-effective, but rather by achieving its goals. Therein lies my objection to raising the issue of medical cost-effectiveness. The most important variable in cost-effectiveness is defining the goal, so as to know if you are being effective in achieving the goal. It would be cost-effective to focus efforts on coverage of the most vulnerable. It would be cost-effective to stop treating the elderly, the disabled and the mentally retarded. Sometimes we do things because we feel it is important as a reflection of the quality of our society. Economic reasons alone are not good enough to make decisions about health care policy, something I was taught by a health economist from Harvard.

There are some very valid notions being floated regarding health reform, not the least of which are reducing payments to hospitals (which account for 50% of the country’s health care bill), increasing transparency of pricing and increasing consumer control of their own health care money and benefits. These proposals address many problems in health care today, but not the problems of those who need the greatest assistance. At the risk of sounding like a guild monopolist, physicians are better representatives of patients when they cannot speak for themselves than a policy wonk who’s never walked a day in clinic.

The first step in crafting health care policy is articulating a role for government. If you don’t believe there is any role for government in health care, then we have nothing more to talk about and we must agree to disagree. If the goal is a responsible approach to improving the well-being of the population through expanded health coverage while simultaneously improving accountability of the tax dollar, then there is a possibility of discussing the relative merits of various approaches.

USA Today Health Reform Editorial

Here is one Michael Cannon would prefer to forget. The problem with the ideologues is that they learn to reference their papers after they’ve written theM. So often, the articles do not say anything about what is being referenced. This is why I do not often use material from think tanks unless it is clear to me they do not have a political agenda and treat facts respectfully, with reason and an absence of rhetoric. From The Physician Executive in September in 2007. I will never delve this deeply into ideological clap-trap ever again! 


Dear readers, I need your help.

As you may know, I am a proponent of a non-dogmatic approach to policy debate and would like to see some truly conservative approaches to health care reform. I despise the tools of rhetoric and the use of formal logical fallacies that characterize the current crop of so-called conservatives.

Yesterday (via InsureBlog), USA today published an op-ed by Michael Cannon of the Cato Institute, an organization which I usually find provocative and challenging, but not thoroughly manipulative nor responsible for shoddy scholarship. I reviewed the articles which Mr. Cannon offers as references and have trouble connecting the articles to the point being made. There are also some logical inconsistencies.

Here is a systematic breakdown of what I found:

1. US Census Bureau. Nothing wrong here, the Bureau’s number may very well bear re-examination since all surveys have strengths and weaknesses. There is no such thing as methodological perfection.

2. Agency for Health Research and Quality: “other recent surveys put the number between 19 million and 36 million” for the uninsured. The link takes us to a MEPS survey (Medicare Expenditure Panel Survey is a running survey of medical expenditures using a representative sample of the entire US population) which does not support Mr. Cannon’s statement. The study delves more deeply into the census bureau’s figures by looking at the duration of being uninsured. The census bureau counts people as uninsured if they have been uninsured for any time n the past 12 months. Since the public health concern is identifying a vulnerable population, this is an entirely valid definition. The MEPS survey states “In 2003, 25.4 percent of the population was uninsured at some point during the year, 18.8 percent was uninsured throughout the first half of the year, and 13.6 percent was uninsured for the entire year.” Even math errors on Mr. Cannon’s part does not explain why he is comparing the proportion of American uninsured for the first half, second half and at any time of the year.

3. The next link is used to support the phrase “As many as 20% of the “uninsured” are eligible for government health programs, so in effect they are insured.” This is the most egregious. It comes from data that many who are eligible for Medicaid do not sign up since 20% of those eligible are not signed up for SCHIP. The statement holds true only if all the uninsured are eligible for some kind of government program, which is inconsistent with a seprate implication, presented with no evidence, that so many of the uninsured are illegal. Moreover, it escapes me how someone who is eligible for a program is still covered if they chose not to sign up. How does this address the vulnerability associated with catastrophic health expenditures? Moreover, the study referred to is a sober and numbing methodological comparison of the MEPS and Census surveys, not one of the many studies which have demonstrated repeatedly that under-utilization appears to be the hallmark of programs like SCHIP.

4. Mr. Cannon uses a study by Bundorf and Pauly to support the statement that as many as 75% of the uninsured can afford insurance. The paper is a fascinating and illuminating look at the effect of different definitions of affordability on the population estimate. While 76% is the high end, 31% is the low end of the estimate. Their findings support a statement much different than Mr. Cannon’s, here I quote from Bundorf and Pauly’s conclusion: “Our results demonstrate that lack of “affordability” is an important barrier, but not the only or the major barrier to obtaining coverage for all, or even most, of the uninsured. […]Omitted variables related to health status are potentially of particular importance. If our measures of health status do not capture characteristics of individuals that result in unusually high premiums (potentially due to risk rating of premiums or denials of coverage in the individual market, for example), we may over estimate the affordability of health insurance for high risks. […]Deciding for whom health insurance is affordable is ultimately a normative decision on the part of policymakers and society. We believe that our definitions, however, offer researchers and policymakers a positive empirical framework with which to begin to evaluate this question by basing the definition of affordability on the behavior of other consumers with similar characteristics, rather than an arbitrarily chosen income threshold.” This is very wise, unlike Mr. Cannon’s inexplicable peripatetic diversion.

5. To support the statement that “many economists can find no evidence that it [expanding coverage] is a cost-effective way to improve health” Mr. Cannon uses a non-peer reviewed piece of secondary literature that is actually an interesting review of the literature with respect to causality between insurance and health. The reviewers observe that if the causal chain fails, it may be either health insurance or health care that may not improve the health of the population. That is an established fact, which is not at issue because we are talking about extending health coverage to vulnerable sub-populations. The poor represent the majority of the uninsured unless you believe the prior misinformation. Perhaps the argument against covering the uninsured is being used as an argument against either government run or universal health insurance.

6. A rapid sequence of references asserting that expanding health coverage will not

a. Improve quality: New England Journal article shows that income is more important than race. The study does not address access to which coverage is most relevant.

b. Reduce disparities: Paper argues that reducing poverty is more important to health than improving health care access.

c. Affect life expectancy: A New York Times article about education being related to longevity.

d. Reduce cheating: A Health Affairs analysis of how health care costs for the uninsured are currently distributed. No mention of how not having a program deters cheating on the aforementioned non-existent program, i.e. Mr. Cannon’s argument is nearly circular.

7. The Kaiser Family Foundation says that the average family of four spends $11,000 a year. Individuals are pegged at $4,000. What the average cost per employee is, I just don’t know. Using one number without the other is not an honest presentation of the problem and I may be a little dense here… what was the point? Health care is expensive? We know that.

8. Several correct citations regarding the number of people covered by employer-sponsored insurance, rise in health insurance premiums, a White House press release, Rudy Guliani’s campaign website and a CBO letter.

Please review what you can (not everyone has full text access to Bundorf & Pauly) and let me know if I have mis-read any of Mr. Cannon’s references. Please note the title of the editorial refers to making Americans care about health care. This is a very promising position. I hunger to hear the argument, but am I just dense, or did he completely skirt around the cost, except a passing mention of average family insurance expenditures? I think there are extremely cogent arguments to be made.

Costco, Fashion and Health

I share a lot with the society in which I live.

Shopping at Costco, you always notice the overstock items run in a small number of sizes. Somebody overestimated the number of items manufactured in a given size. Sometimes it’s easy to find your size, which probably means it was either butt-ugly or mis-priced.

My size is not easy to find. People with 18 inch necks are not usually 34 sleeve. You can find 18/36 and 17/34, but 18/34 just ain’t easy.

I have message for the “shmatta” industry: America is getting fat! I’m not proud of it, but facts is facts and I’m not getting any younger, thinner or hairier on the top of my head. America is getting fat and the population’s obesity no longer looks like a bell curve. Stop making clothes for the ideal of the human form and you will lose less money in unsellable overstock.

One good thing: tomorrow is the day I will start to exercise, knowing I finally found an 18/34 this weekend, just in time for Valentine’s Day.

State Licensure: Quality Assurance or Trade Barrier?

When I moved to Washington from Maryland, it was a difficult transition. The worst part was getting to my new job earlier than anyone thought I could, but then having to sit around and wait for my license. I worked hard trying to familiarize myself with the organization as best I could. But it made me think … this post was written in 2008.


It is hard to believe that The Physician Executive has not yet received his new state license. It has been over six weeks, but physician readers will not be surprised. Fortunately, our insurers have already assured us that the moment the license is verifiable online, they will honor charges in his name.

In Maryland, the Board of Physicians says it takes 120 days to obtain a license (it usually goes faster). The last time I looked into California, it was over six months. States that decide they are over-doctored typically take longer than other states. There may be something to that, since I have heard of some primary care physicians having a hard enough time finding work that they are considering leaving California. But to be fair, I don’t know if a couple of anecdotes are worthy of calling it an established trend; I will be watching.

The reason it takes so long is something known as primary source verification. Licensing boards are diligent in verifying every employment situation, every hospital affiliation and every training site. Sometimes they go so far as to verify every locum situation as well. If a physician has worked for a single weekend covering a rural hospital, someone will want to verify it. Even thirty years later.

This needs to be done.

But it generates an awful lot of paperwork.

Since some of my former employers are closed, it creates challenges in identifying the correct individual to provide important verifications. Unsurprisingly, many Canadian residencies are less concerned with American credentialing than I am. My former internship site is apparently renovating and having trouble finding documents for some guy who left the country ten years ago.

Such is life.

The trail is long and I am a bit of a Donabedian groupie, so I don’t have a problem with primary source verification. However, there is an awful lot of overlap. There is the National Practitioner Database and the AMA, which offer some degree of triangulation, even though they are primarily a method of identifying complaints, lawsuits and other problems. Employers also do their own primary source verification, that way employers do not need to stay familiar with their state board’s processes. In one instance, the state board was able to obtain verification and the employer was not. The employer insisted on a signed affidavit.

Then there are the insurers. One company I am familiar with refuses to begin a credentialing process until everything is in the file. Then it takes them four months to review. Then they do not pay for any services provided during the credentialing process. I understand the importance of credentials verification, but this sounds a little like manipulating a process to their financial advantage. Yes, I am talking about you, Amerigroup. (Gratuitous stock advice: consider buying the stock, but never the insurance.)*

I would never advocate the elimination of licensing requirements (if I hear someone quote Milton Friedman on the subject one more time, I will subject them to the merciless ridicule reserved for followers of cults, star energy, homeopathy and other quackery), but there are certainly some implications for a free market in health care. There isn’t one.

We could streamline licensing procedures and credentials verification across the country. The CAQH already has electronic tools to facilitate the credentialing process. It would open up interstate competition in health care. (In a subsidized environment, heath care is driven by practitioners, so the competition is between jurisdictions and employers to attract them, not between practitioners to attract customers.) The problem of mal-distribution of physician resources would likely continue, but there are a very few examples of regulatory incentives to encourage physicians not to settle in cities or suburbs. Physicians flock to nice places to live until they start going belly-up. Or working for MinuteClinics.

As it stands, as a CMO, I am competing with much wealthier jurisdictions and facilities and then faced with an outsized regulatory burden to verify my practitioner’s credentials and facilitate our payer’s verifications. Moreover, the barriers to interstate movement of the medical labor force is at a level that makes me think of protectionist trade barriers.

I hope to see my first patient next week.

*I suppose there should be a disclaimer about the fact that my comment is meant sarcastically and not intended to represent real stock advice etc etc, but I assume that my readers are intelligent enough to figure that out for themselves. Caveat emptor.