Pearl Harbor Day. World War 2 and the American Spirit

Yesterday was Pearl Harbor Day. Mostly forgotten now, although we remembered it pretty well for many years. More than we remembered 9/11, really. I remember telling Emily after 9/11 how soon the horrible memory would fade from the American interest. It's how we are today, every hot event fading into the next news cycle.

I was only age 3 at the time so I don't remember the event, but the war went on for 4 more years so I do have memories of the times. In fact probably one of my earliest vague memories was of an air raid drill where my mother had to turn off the lights and pull the shades at our house in Pittston. I couldn't have been much more than 4 then.

That war was definitely different from those of today in that it wasn't fought by the military alone. Since then we've had "guns and butter", but not then. The whole population was intensely involved. Things back home were rationed since they were needed for the war effort. I can remember the gas ration stamps which entitled you to only so much unless you were needed for a critical job. Many other things were rationed, rubber, butter, nylon stockings and on and on. Auto plants were converted to manufacturing tanks and planes, so forget new cars. Sports were suspended since all the players went to war. The culture changed. Women went to work instead of staying home to replace the drafted men.

The whole country pulled together. There had been plenty of anti-war sentiment before Pearl Harbor, probably the majority. After the experience of WW1 nobody wanted to get involved in the crazy internecine feuds of the Europeans. But a deadly sneak attack in those days didn't sit well with the Americans. They didn't weep and wail and put up memorials. They got mad!  And FDR, regardless of what you may think of his social programs, was a superb wartime leader. As was his friend Churchill.

After Pearl Harbor, men didn't try to escape the draft, they enlisted. Even if you were afraid you would never admit it because it was  your duty. And for some there was even a certain feeling of excitement to get away from home, which for most at that time wouldn't have happened otherwise. It happened to my 2 uncles, who with both parents dead, enlisted as teenagers to see the world. One, my uncle Ross, came home with a Purple Heart and that meant something then. People proudly displayed their service. A blue star on your window meant you had a son in the military and a gold star was for a son who wasn't coming back. Such families grieved but with pride. The media and the entertainers didn't undermine the war, they promoted the effort. The movies mocked Hitler and Tojo, and esteemed military heros like Audie Murphy. They made movies like the Flying Tigers. And the entertainers volunteered like Jimmie Stewart; some never to come back like Glenn Miller. The government urged us to grow victory gardens and save tin cans.

We knew who was our enemy and put it right out there. I can remember in first grade making stick drawings of "Jap" planes being shot down by the red, white and blue. The war was fought with ferocity, all out and everybody contributed. And the industrial output of everybody working together overwhelmed 2 mighty enemies on 2 continents. It was fought to the finish in 4 years. It's a long time ago and I was little but I can remember the elation of VJ Day.

Today we're at each other's throats. War is some distant event, not even raising the interest of the TV cameras. 9/11 15 years later stirs up little fuss except for 1 day a year. It's pathetic really when you think about it as we should today.

Blood Glucose Testing, CGM and FreeStyle Libre

At our support group sessions we've talked about home blood glucose
testing. I encouraged almost all of my patients to do it, even those
with minimal problems. For the most part blood glucose cannot be
perceived and testing is necessary to know your levels and get
important feedback as to the influence of various factors. A1c is
useful as a guide to blood glucose control over the long term but does
not give information about daily fluctuations.

The timing of testing is important. Blood glucose fluctuates
throughout the day depending on food intake, activity level,
medication effects, and many other factors such as psychological
stress and the many hormones that the body manufactures and emits
intermittently. Key times to test are before and after meals. Diabetic
patients with type 1 and those with type 2 on complicated insulin
regimens should test several times daily.

The majority of type 2 patients taking less complicated treatment, and
particularly those with consistent meal and activity schedules, tend
to have a stable blood glucose pattern, rising and falling  in a
similar manner on a daily basis. For such patients I recommended a
less intense amount of testing, still testing at key times mentioned
above but limiting the number of days of testing to between 1 and 3
days weekly. The point with this approach is less to adjust things on
a daily basis and more to try to pick out a pattern, particularly of
high or low times during the day, which might be used for longer term
treatment changes. Doing this is much more useful than the common
practice of testing daily before breakfast which measures glucose at
one point in the day but misses all the rest of the fluctuation.

A more recent approach to blood glucose testing is with CGM
(continuous glucose monitoring), using a tiny glucose sensor which is
inserted under the skin and which measures and transmits blood glucose
information every few minutes to a remote monitoring device, such as
an insulin pump screen, a cell phone or even a wrist watch device.
Tremendous strides have been made in the development of these devices
in recent years, especially in accuracy and duration. In fact the most
recently available sensors work out of the box without calibration and
can be used as a substitute for finger sticks and give accurate
results for up to 7 days.

Continuous glucose monitoring is fast becoming the standard of care
for treatment of type 1 diabetes, primarily because one receives not
just a real time blood glucose reading, but more importantly because
trends are identified. It is more important when using insulin to
understand in which direction the blood glucose is heading and how
fast. Also because of this ability to show trends, CGM devices can
give out alarms that warn when the blood glucose is heading too low or
too high.

CGM devices hold great promise in the quest for automating insulin
treatment since their data can be linked wirelessly to insulin pumps,
thus advancing toward the promise of an "artificial pancreas". Many
innovators are working diligently toward this goal. However, as CGM
devices have become easier and simpler to use it seems to me that they
should be useful for monitoring of blood glucose in type 2 patients as
well, not constantly, but periodically, as a better way to do the
intermittant analysis which I mentioned above. For this purpose a less
expensive easier to use device with less high tech features would be
most desirable.

Today's newsletter was actually prompted by my happening upon news
about the soon to be marketed FreeStyle Libre. This is a somewhat
lower tech and lower cost CGM device that looks to me like it would be
good for most type 2 patients and would even make sense for those type
1 patients who wish to continue with insulin shots rather than a pump
and could reasonably take the place of most of their fingerstick
testing. The sensors are unobtrusive, about the size of 2 stacked
quarters and look like a cinch to apply. They can be kept on in the
shower and even be used under water for a short time. Instead of a
continuous display on a monitor as with most sensor systems,
information is transmitted to a small, low cost monitor when it is
passed over the sensor, like items at a checkout counter. Whenever
this is done, on the monitor screen appears your present glucose
reading, a graph depicting what's been happening over the last 8 hours
and an arrow indicating which direction and how rapidly your glucose
is changing. In addition various graphs useful to analyze the last 90
day's data can be called up on the screen or downloaded to a computer.
The rechargable monitor device is supposed to sell for $60 and the
sensors which last 10 days I'm told will sell for $40, far lower than
the other available CGM systems. These prices might be particularly
appealing for Medicare type 2 diabetic patients for whom CGM is not
covered and who might use the devices only periodically to analyze
their blood glucose responses. If I were still in practice I would
certainly be interested in using this system to analyze my patients.

More information can be found at https://www.freestylelibre.us/

The AMA Does Not Represent Most Doctors. Vote For the Graham Cassidy Bill.

I received a "wire alert" email from the AMA asking me to contact my senator to advise him to vote against the Graham-Cassidy Amendment. The AMA has always had a political function but primarily one devoted to the advancement of private medicine. It's leadership is now fully invested in government controlled medical care with their organization being a major player. I stopped paying my dues 10 years ago after it revealed all its cards and came out in support of Obamacare.

What I am going to do in response is to advise my senators to vote in favor of the Graham-Cassidy Amendment. Of course that will be mostly a waste of time since both Pennsylvania senators will be voting along party lines.

But I also am going to recommend to you readers of these posts to support it. Government and other third party involvement in our health care over the past 5 decades has resulted in high prices, ridiculous regulation, stifling of service innovation and shifting control of health care decisions away from patients. This new bill is far from a solution to these problems but passage in the senate would at least get the matter into a conference committee with the house where a reasonable new law could be worked out. As incompetent as the present congress seems to be, many of the members as well as HHS Secretary Price understand the principles which would devolve medical care back to the control of patients and medical providers. We must get our health care out from under the control of the government and their third party allies.

And by all means do not be fooled into thinking that the AMA represents the thinking of the majority of American doctors. It does not.

What is the point of the NFL "kneelers"??

Overall I think the NFL controversy is pretty dumb. But one thing does mystify me. What exactly is kneeling during the national anthem supposed to signify. I guess it means that you don't like the country. But what about it don't you like? The laws, the people, the climate? What is it?

Is it the fact that we have the disgrace of a minority ghetto in almost every big city, plagued by crime, violence, dangerous schools, unemployment, welfare dependency, fatherless families? But what's the cause of that, and how does condemning your country help to solve it?

What exactly is the outcome that is going to satisfy the incessant race consciousness in our country? It was supposed to go away when we got our first mixed race president, but it seems to me that it has just gotten worse. Where are we going with it? Nowhere good.

Is Paying for Medical Care Out Of Pocket Really a Crazy Idea?

We're so used to paying for medical things by insurance or through government programs that it seems crazy to suggest that we should pay directly out of pocket like we do everything else. How can we afford those high prices? What does the ordinary person know about what tests or treatments he should have? One of my liberal friends laughs at me and asks me if I'm having a heart attack how I bargain with my doctor or hospital over the price.

OK, well what about the high prices. How can we afford them? Think about it. Who does pay them. Well we all do. If we pay our medical bills through insurance that we get from our job that premium is part of the compensation for our work. We get it instead of wages. And Medicare is paid by our taxes and premiums and add-ons to the national debt. It's not some rich guy being forced to pay, it's us.

OK, in reality we pay the bills. But really, what about the high prices! Well technology is expensive, that's true. But we buy lots of expensive things by ourselves, like houses and cars and vacations. And a lot of medical stuff isn't all that expensive. The monthly Comcast bill is as much as the average doctor bill. The statistics say that most of us actually pay more for entertainment than for health care.

Actually if we paid for most of our medical care directly out of pocket it would be much cheaper. What?? How could that be? Well here's how the economists tell us the free market works. Consumers actually run the show, not by bargaining as my uninformed liberal friend thinks, but by choosing what most satisfies them at the best price. If something costs way too much they go without it if it's not that important. Or if it is important they substitute something else that works for them. Like I might look in the Mercedes showroom but I buy a Chevy which basically does the job I want. But why do economists say that consumers run the show? Aren't they at the mercy of the big boys. Well actually the producers have to figure out what the consumers want and then compete against their rivals to make something worthwhile at a price they'll pay. If they do that they prosper. If they don't they go out of business and go to work for somebody else. So the free market works to give people what they want at the best possible price and if you do that really well you get really rich. Take good old Henry Ford for example. In 1908 when he started he sold about 6000 Model T's for $850 apiece. By 1916 he had got the price down to $360, he sold 577,036 and he became the world's richest man.

Despite all this, in our country we have this idea that when we're buying medical care we shouldn't have to bother our heads about the price. I can actually see where that idea comes from. Medical care is pretty important and some of us really might be in that position of having to go without unless we get a little help from our friends. On the other hand we pay directly for lots of things that are just as important, like food and shelter. For these things if someone's on hard times we help them out but we don't revamp the whole darn system. Any guesses what would happen if the government took over paying for all our food or houses?

The other argument I've heard is that the common folks just don't have enough technical knowledge to make the right choices. How arrogant is that! We're just going to do this little operation on you, and don't you worry, it's free. When I'm picking out a car do you think I inspect the engine and decide based on all those technical specifications they have in the brochure? Yet somehow I come out with something in my price range that fills the bill. On the other hand in the area of medical care I do know what I'm looking at when I peek under the hood and I can tell you a couple of things: 1. you pesky patients have an awful lot of opinions on what you want and how things are done to you, and 2. there's a tremendous amount of flexibility in how we can do most things you want done. So if you're paying the bill we can work with the price. For that matter, if I ask you to get some lab work done, how much technical knowledge does it really take to go to the place with the lowest prices. But has any of you ever seen a lab that advertises its prices?

Here's the main point. Our medical care isn't free; we're all paying the bill. And not only isn't it free, it's very, very expensive, largely because we've got this arrangement that makes us act like it's free. And added to that there are tremendous wasted administrative costs both for the payers and for the providers just to make the system operate like its free. AND added to that we get the hell regulated out of us so we have to ask permission just to get what we're paying for. So which system is really the crazy one?

I'm going to keep going. I've got lots of good examples to prove the point.

Fixing Obamacare Will Not Fix Our Health Care System

Chuck Schumer says he knows that Obamacare is flawed but that we should fix it and not repeal it. What exactly is the problem with Obamacare and how is it to be fixed? In the eyes of the politicians, specifically all of the Democrats and many of the Republicans, the illness of our health care system is that some of us are "uninsured" and that the government should arrange to "insure" those who are lacking. If we work that out they will have done their job and everyone will be happy.

That fact is that the problem with medical care economics in our country is much more fundamental. Our peculiar system of indirect payment and insurance company and government intervention where none is needed is responsible for price inflation, wasted medical goods and services and gross bureaucratic interference that produces no health benefit at all. Obamacare is the wrong treatment for the wrong diagnosis and "fixing" it will not cure our illness. It simply adds more people to a bad system and does a lot of counterproductive things at the same time.

I recently visited a doctor for my own problem. At the registration desk I waited 10 or 15 minutes for the lady in front of me to get all her insurance information recorded, get her picture taken, put her signature on several items and on and on. We're all so used to this nonsense that we think of it as normal. In my practice there were personnel whose whole function was to attend to billing. Others oversaw adherence to Medicare and Medicaid regulations. My nurse spent hours daily seeking pre-authorization rather than interacting with patients. I was obliged to buy expensive computer systems and pay regular high IT fees just to comply with billing activities and documentation to justify my claims to the payers. The bill payers on their end required personnel and computers to handle similar administrative work. All of this activity depends on a system of extensive coding of each of thousands of medical items and services. Millions of dollars are spent paying organizations to devise these coding systems. Millions more are spent on bureaucrats and consultants to meet, categorize and devise value to each code.

To make claims to the payers for my service I used these codes and I documented what was necessary to justify each code. Such documentation requirements were far in excess of what I would need for actual medical communication and took large amounts of time from patient interaction. Many doctors because of this have added a new employee called a "scribe" whose function is to attend to the documenting, another layer of personnel cost. One study recently estimated that 50% of physician time is spent on administrative work.

Space limitations preclude a full description of the regulatory cost and time loss of our present system just in this one area of the doctor visit, none of which has any patient care value. It is a tremendous waste of resources, the cost of which is ultimately borne by medical consumers.

The alternative to this system would be simply for the patient to pay at the desk by cash, check or credit card. With direct payment major personnel and equipment reductions as well as the office space to house them would occur. In addition major diversions of doctor and nursing time would return to patient care. My best estimate is that direct payment would translate to at least a 25% reduction in my office fees and at the same time an increase of about 20% in time spent with patients. I cannot estimate the savings derived from decreased involvement of insurance companies and government bureaucracies but they would clearly be substantial.

I often hear people say that they had such and such a procedure and didn't pay a cent. It's an illusion friends, a scam really. Not only is your treatment not free, it is very, very expensive. All these billers, coders, clerks, scribes, bureaucrats and consultants must be paid and none of them are doing a blessed thing to attend to your medical problems. And all these goings on are just the tip of the iceberg that is the wasteful, inefficient, paternalistic, bureaucratic system that we've become adjusted to over the past 50 years or so. Stay tuned.

American Universal Health Care

America leads the world in medical science and technology. At the same time our system is plagued by inflated cost, grossly excessive third party interference, lack of incentive for efficiency and innovation of services as well as considerable variation between individuals in accessing the system. It is time for us to address these problems and become the leader in medical care delivery as well as technology with a uniquely American system. The basic principles for doing this were laid out in the last post. They involve the following: 1. There should be direct payment for ordinary medical expenses rather than through third parties, 2. Incentives should be given to individuals to devote a portion of their income to savings while they are young and healthy for inevitable future medical costs, 3. Low cost, personally owned, medical insurance should be widely available to pay for unanticipated catastrophic medical events, and 4. A government safety net, supplemented by charitable organizations, should be in place to provide basic, good quality medical care limited to those who need it rather than the general public. This safety net system should be individualized and as free as possible from waste and abuse.

There are good practical steps which health care economic experts have been proposing for many years that would make the transformation. Some of these ideas actually coincide with substantial parts of the long term goals of the recently proposed Republican health care plans. Unfortunately they were released to the public in a hasty and obscure way, without much debate or explanation, leaving many uncertain and reluctant. Some of the reason for that is that from the political standpoint achievement of these principles would need to be done stepwise over time so as not to disrupt those who have planned and adjusted their lives to the present system.

Since the 1940's the federal government has excluded the value of employer based health insurance from both income and payroll taxes. This is an unfair government subsidy which favors those who receive this employee benefit over those who do not and which favors those with higher incomes who pay more taxes. Healthcare tax incentives are a reasonable policy of government but if they are to be given they should go equally to every individual. Moreover our reliance on employer provided health insurance has a number of disadvantages. These include an overdependence on using insurance to pay for medical services, severely limited choice of policies, and a constraining linkage of medical care access to one's employment. The system obscures the actual value of wages and it involves the employer in an area in which he has little expertise. (For a fuller discussion see http://tinyurl.com/yayxdrpj). This tax exemption policy should be converted to one which applies to all and which incentivizes savings for medical care and promotes medical insurance policies which are personally owned and which are not linked to one's employment.

The best way to do this is through the idea of Health Savings Accounts (or HSA's) which are individually owned funds used to pay healthcare expenses. Although at present HSA's form only a small portion of the health insurance market they are its fastest growing segment. The owner of the HSA pays ordinary medical expenses directly from the account instead of through insurance, usually using a credit card or check. HSA's are administered by banks in a manner similar to a personal checking account. but, like an IRA the savings are tax deferred. Money in these accounts can be used for a much wider range of health related expenses than standard insurance and any savings by prudent shopping remains the property of the owner rather than the insurance company. Over time substantial amounts can accumulate and in essence the owner is self insured. Funds can be used only for health related expenses but under present law they may be withdrawn for any use after age 65. (For a fuller discussion see http://tinyurl.com/y7srksxh).

Despite their growth, the market for HSA's has been significantly restrained by government imposed funding limits and utilization regulations. In general those who favor government controlled medical care have opposed the concept. Under present law they are required to be tied to a high deductible insurance plan and cannot be used for health insurance premiums. Such restrictions should be eliminated and any amount of funding should be allowed. HSA ownership should be widespread and strongly encouraged to be the primary mode of payment for medical goods and services. Ownership of an HSA at an early age, similar to the social security account, should be the standard in our country and would become the "universal coverage" that so many desire.

Funding of personal HSA's can be done by individuals themselves and this is encouraged by the tax benefits and their eventual possible use for retirement savings. However others, such as employers, can contribute to them and ideally this could be the primary source of funding for many. Money that today goes to insurance companies would go directly to the private tax deferred accounts of employees to use as they see fit. Those with chronic disabilities, severe illness and low income would also be HSA owners which would be funded from government or charitable sources, thereby replacing the patchwork of present day government programs with their wasteful policies and oppressive costly regulations.

For the HSA owner, insurance assumes its rightful place as a protection against very high cost unexpected events and not as a payer of ordinary expenses. HSA funds would be used for premiums and thus policies would be personally owned, independent of one's employment and suited to one's medical needs. Such high deductible insurance is cheaper but changes in federal insurance laws would help to lower insurance prices further. These would include allowing health insurance to be sold nationally, elimination of coverage mandates, and authorizing associations other than employers to sponsor policies so as to take advantage of group coverage. Most importantly if direct payment for medical expenses became the dominant mode, market forces would cause substantial price reduction generally which would strongly affect insurance prices.

Over the decades multiple interventions into our health care system has left it in a highly complex disordered state. Many people find the discussion of how to correct the system confusing. The idea of complete government takeover is tempting to many because of its apparent simplicity. But impersonal government programs bring with them waste, inefficiency, stifling of innovation and oppressive bureaucratic regulation. The next post will detail how the plan outlined above promises to dramatically lower medical prices, make services far more efficient and personal and open the floodgates for innovation in medical care delivery.