Nothing in this world is free, nothing.
Not even freedom. Especially not freedom.
With freedom comes choice –
They cannot be separated.
The free man must always choose,
And with choice comes consequence.
The free man is responsible for his consequence.
Freedom is never ever free, of responsibility.
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Last weekend, after I gave a speech at a public forum about healthcare, a woman came up to the podium and asked me a question. “My daughter was just accepted to medical school. Do you think she should be a doctor?” This should have been the easiest question ever, but was the opposite.
I come from a family of physicians going back more than three generations. It is what we did, what we were. At a family gathering several years ago, I counted at least 14 men or women who were practicing physicians. Three of the fourteen doctors had married medical school classmates, raising the ‘family’ number to seventeen.
Our family believed that the highest calling for a human being was to heal other human beings. So, it should have been easy and immediate for me to say to the mother at the podium, “Of course, your daughter should be a physician. There is nothing better in the entire world!” It pained me not to say that.
A recent Wall Street Journal article written by another physician, more precisely ex-physician Dr. Ed Marsh, expresses several emotions all too common in the community of health care providers: doctors, nurses, and allied health personnel. We are angry, frustrated, and confused.
Prematurely retired Dr. Marsh summarized: “The glow of the personal relationship one might have with one’s patients [the reason we get up in the middle of the night for you] is being [actively] extinguished.” He speaks for virtually all doctors, nurses, and care providers, everywhere, not just in the US.
Dr. Marsh is anything but an isolated case. I too gave up clinical medicine last October, most reluctantly. I love caring for babies and still miss doing it. Forty-to-fifty percent of practicing doctors are now thinking about early retirement.
The national data on provider shortages is clear. From 1995-2008, admission applications to US medical schools fell by almost 20%. Last year there were 110 accredited training positions in heart surgery in the US. Sixty applied. There are roughly one half a million unfilled nursing positions here.
Compared to other nations, the US ranks #1 in spending on healthcare by a very wide margin. In 2010, we spent 17.6% of GDP. Germany, in second position, spent 11.6%.
What did We The People get for all that money? The US is #34 in infant mortality; #40 in population longevity; #81 in hospital beds per 1000 people. The US is #52 in doctors per 1000 people (2.3) but we maintain our top position in lawyers per 1000 people (3.7).
The explanation for the personnel shortages, as well as early retirements like Dr. Marsh and me, was made public many years ago. The #1 dissatisfier of care providers was job environment. Money – lack of it – was not statistically significant. Interestingly, the #1 satisfier of care providers was job content.
Put as bluntly as possible, we love caring for patients and hate the environment or system in which we are forced to do it. This distinction is quite timely in view of a recent Harvard Business Review article titled, “The Happiest People Pursue the Most Difficult Problems.”
The author, Rosabeth Moss Kanter, wrote the following. “The happiest people I know are dedicated to dealing with the most difficult problems. Turning around inner city schools. Finding solutions to homelessness or unsafe drinking water. Supporting children with terminal illnesses. They face the seemingly worst of the world with a conviction that they can do something about it and serve others.”
Kanter is both right and wrong. I love the act of caring for sick babies with congenital heart disease. I hate having to fight, threaten, cajole, and sometimes, outright lie in order to get those blue babies what they need.
Twenty years ago, management guru Carl Weick gave us the answer, without knowing it. His classic 1993 paper “The collapse of sensemaking in organizations: The Mann Gulch Disaster” described the “cosmology episode,” where the basic rules of life do not exist, and the world makes no sense.
In a cosmology episode, you throw a ball up into the air, and it never comes down. In a cosmology episode, the sun rises in the south. In a cosmology episode, black is white and red is orange but may suddenly change to green.
In healthcare today, the patient perceives the provider as an enemy: cosmology. What do providers experience? Answer: cosmology episode in the form of roadblocks where there should be wide-open freeways; reasons why they can’t do what the patient needs; and punishment for doing good deeds.
The ball didn’t come down? No sun rising in the east? Provider trying to save you is labeled a “perp” (perpetrator)? Makes no sense, no sense at all! That is the world in which today’s health care provider lives.
No wonder care providers are confused, frustrated, and angry. Wouldn’t you be? No wonder they are leaving healthcare (the system) even though they love providing health care (the service).
(This article previously appeared in American Thinker. It is worth your time reading the comments, especially from other practicing physicians, most of whom have quit, for the same reason as I did. While this is most sad for us as providers, it is [or should be] terrifying for We The Patients.)
What should I have answered the mother of the pre-med student? If you were in my shoes, what would you say?
Note about author: Deane Waldman MD MBA is or more accurately was a pediatric cardiologist who retired from clinical practice saying, “I cannot practice good medicine under Obamacare.” If you really want to understand what is happening and why, read his forthcoming (July 2013) book, The Cancer in Healthcare.
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Shouldn’t the people we vote into power provide role models for how We The People should behave? I would hope that is a rhetorical question, but apparently it is not.
Obesity is by far the most costly and yet preventable illness facing the United States. The doctor who is the titular head of the US healthcare system would naturally lead the effort to address the problem. How much credibility does US Surgeon General, Dr. Regina Benjamin (panel A below), have in the fight against obesity when she is its poster boy?
On the subject of obesity, watch for a sequel to Cutting healthcare costs by killing patients (2/27/13), called “Cutting healthcare costs by saving patients.”
Organizationally, the IRS is under the control of the Dept of the Treasury. You would naturally expect, as I did, the Secretary of the Treasury to set an example for all tax paying citizens. What kind of role model was former-Treasury Secretary Timothy Geithner, a man who forgot or mistakenly filed his tax returns?
The President of the US clearly is or should be our best role model, a paragon of honesty and integrity that we all should emulate. (“Honest Abe” Lincoln immediately comes to mind.) How does one then understand the pattern of lies of which President Obama has been proven guilty?
As evidence, consider the following: Obamacare (where you cannot “keep your doctor if you want to”); the slaughter of four Americans in Benghazi (Hillary Clinton fell on her sword to protect the President); and most recently, “I had nothing to do with that” (the Sequester.) Read Bob Woodward’s article that proves the author was, indeed, Obama.
To provide full disclosure, Democrats are not the only people in Washington who provide us with “reverse role models.” When thinking of Republicans, the names is John Mitchell (Attorney General under Nixon) and Spiro Agnew (39th US Vice President) immediately come to mind.
However, the bulk of “blame and shame” belongs to Democrats. They consistently assert ownership of the moral high ground. It is therefore ironic and frankly alarming to find that their claim to moral superiority is as disingenuous as most everything else they say.
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UN Resolution 260 (III) – Convention on the Prevention and Punishment of the Crime of Genocide – was signed on December 9, 1948. It memorializes a worldwide consensus against State-sanctioned killing of people by groups. The convention protects “national, ethnical, racial or religious group[s].” The Convention forgot to protect a group called the expensives.
Nation-States are once again killing people wholesale, this time based on their costliness, rather than according to their place-of-origin, skin color, religious commitment, political affiliation, or ethnicity. In order to cut healthcare costs, Great Britain’s vaunted NHS eliminate (kill) patients whose only crime is being expensive to treat.
Supporters of the ACA such as President Obama and Dr. Don Berwick openly and proudly said that Obamacare was modeled after the British National Health Service (NHS). It is reasonable to expect that what the NHS has done in England will be done here. Additional letter-abbreviations that must be added to our body of evidence include NICE, IPAB, LCP, and WaSEPTS. Each will be explained.
Cutting Costs
Virtually all conversations about healthcare devolve quickly to cost cutting, as though saving money were the purpose of healthcare. It isn’t. Healthcare’s true function is to have healthy, long-lived people. If cutting costs does not achieve that goal, it is producing the opposite result from what we want.
You and I may talk about the “cost” of a car or a hernia repair, but only the manufacturer of a product or the provider of a service can cut true “costs.” Consumers and payers can only reduce their spending.
Consumers reduce spending through the free market, which balances supply and demand through competition and price variability. Third party payers – private insurance and government agencies – achieve balance by decree rather than using market forces. To reduce its healthcare spending, the government cuts payments for health care services. For expensive patients, it may choose to cut payments to zero. This translates to “no payment = no treatment.”
NICE (England) and IPAB (US)
Sarah Palin’s “Death Panel” accusation on Facebook in 2009 turns out to be true. The name of this death panel is IPAB (Independent Payment Advisory Board), an agency created by ObamaCare. IPAB members are appointed. Its meetings are not open to public scrutiny. There is no oversight.
IPAB is tasked with deciding what medical treatments are deemed “cost-effective” and which are not. IPAB then recommends to Congress that the former be authorized for payment and the latter will not.
IPAB recommendations have the effect of automatic law. Congress can only make substitutions: deleting certain items and replacing them with others. Rejection of IPAB recommendations is not permitted under ObamaCare.
Effectively, IPAB is practicing medicine by making healthcare payment law. Doctors may advise the patient what is best care, but the treatment that the patient actually gets or does not get is decided by IPAB.
IPAB was modeled on the British NICE (National Institute for Clinical Excellence). To project what IPAB will do to us, look at what NICE has already done to the British populace.
Kidney dialysis after 55 years of age and heart surgery after 65 have been classified “not cost effective” by the NHS. Result? If a British citizen is over those thresholds, he or she is … allowed to die (passively) by government mandate.
Though treatments are technically available and medically effective on individuals, they are withheld because of national budgetary considerations. This conundrum was brought before the British Court system.
The British High Court admitted that patients, providers, and the government were “impaled on the horns of a [moral and economic] dilemma.” It goes on to say that, given very real limitations in health care resources, the State has the right to do what it is doing: allowing people to die who could be saved.
As NICE has done to Britons, so IPAB will do to Americans: life or death by government decree. The title of this article is, “Cutting costs by killing patients.” Killing is an active, not passive, act. While IPAB will allow you to die passively, WaSEPTS will actively kill you.
LCP (England) and WaSEPTS (US)
A sign at the entrance to Auschwitz-Birkenau read Arbeit Macht Frei, German for, “Work Shall Make You Free.” Posing as a work camp, people marked for death were taken to the showers supposedly for cleansing. In fact, the “showers” were gas chambers.
Torn down in Poland, these showers were recently rebuilt in Liverpool, England, and named LCP (Liverpool Care Pathway). A sign at the entrance might now read, “Cutting Health Care Costs.”
LCP claims to be “an integrated care pathway that is used at the bedside to drive up sustained quality of the dying in the last hours and days of life.” If that were true, it would simply be better hospice care. The NHS has cancelled all hospice care. LCP is not what it claims to be.
The LCP sedates patients to the point of coma and then withholds nutrients, even including IV fluids. LCP does not ease dying. It hastens death. To physicians, this is unconscionable not to mention immoral and against the Hippocratic Oath we all swore: “I will … never do harm to anyone. I will not give a lethal drug to anyone.”
Everyone responds to incentives. If you give a bonus for scoring points, professional sportsmen and women will score more points. The NHS gives financial bonuses to doctors and hospitals for enrolling patients on the LCP, thus marking them for death. Guess what happens?
There are reports of British citizens being enrolled in the LCP against their will. These people are not asking for help while dying. These are British citizens whom the British National Health Service is literally killing. LCP is State-sanctioned – in fact, State-rewarded – murder of the “expensives.”
What We The Patients want
Cutting costs seems to be what everyone wants, right? For the Nazis, the “undesirables” they put to death were Jews, Gypsies, other ethnic inferiors, and political opponents. Today’s undesirables are expensive patients. As the LCP program has not been formally introduced here yet, it has no name. In honor of the history of this concept, I suggest the name “WaSEPTS” – Washington Sends Expensive Patients To Showers.
In fact, cutting costs is not what we want. In preparation for a new book on healthcare titled, “Not Right,” we asked We The Patients what they (you) want from healthcare?
On two questions, there was consensus, among both liberals as well as conservatives. When asked, “Who is responsible for my health,” 100% of respondents answered, “I am.” When asked who should decide your health care,” without exception, everyone said, “I want to control my own health care.”
How will you feel when the government says that it is responsible and you are not? What will be your response when Washington admits that it – not you and not your doctor – decides your health care?
Conclusion
Cutting health care costs by killing patients is both immoral and ineffective. Killing is immoral per se. When done wholesale by the State, killing is specifically proscribed by international agreement. Reducing healthcare spending this way is counter-productive: it actually increases net costs.
As reported by Dr. Atul Gawande in The New Yorker, Dr. Joel Brenner proved that the best way to cut long-term health care costs was to spend whatever it takes to restore peoples’ health and then keep them that way – healthy and long-lived. That is both cheapest and best, for individual Americans as well as for our nation.
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