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How can Dr Carson be leading in a national poll for president and get a pass on a some, well, scientifically suspect beliefs such as “his statement in the wake of the Oregon mass shooting that it would be advisable to attack an armed gunman during a mass shooting ‘because he can’t get us all‘?” Or. how can folks want a president who is doing infomercials on neutraceuticals which misrepresent scientific fact and when called on it, deny having been paid for what was almost certainly a paid gig?

The New York Times gives a plausible answer to this question today. Ishani Ganguli, a Boston internist with an interest in health policy, points out that, pretty much, physicians get a bye:

  • He points out that we are trained to speak authoritatively regardless of the certainty of the situation or the strength of the evidence. In other words, as I tell my residents, “patients and attendings smell fear.”
  • He points out that surgeons are trained to believe that their skill is what stands between the patient and death and the loss of that faith leads to a crisis, one that a successful surgeon may never experience. He or she may not be good (and there is now a scorecard to look at) but will never admit defeat.
  • Doctors should never be politically correct, or so they are portrayed in the media (see House, MD),
  • There is a long line of physicians who are given a pass (see Dr Oz for the latest example)

Dr Ganguli points out that we as a society feel the need to ascribe trust to the MD. Our Hippocratic sales pitch has been an effective marketing strategy. He goes on to point out that self reflection and knowing our limits are keys to maintaining this trust. I am afraid that these are qualities Dr Carson does not have.

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139263_600Ben Carson on setting up health savings accounts in a post Obamacare world:

“You also give people flexibility to transfer money within a family. So if you were $500 short, your wife could give it to you, your daughter could give it to you, your uncle, your cousin.”

Me in conversation with a fellow who is homeless and suffers from a terminal illness last week:

“Can you give me a ride? I sleep in a cot in the shelter down the way. I worked all my life until I got sick. Just got discharged a week ago from the hospital. Can walk about a half a block before I have to rest. I spend my morning walking to the this place for food.”

Me: “How long does it take you?”

“Oh, all morning. It’s about 3/4 of a mile. I spend the afternoon walking back. The give me a lot of medicines but when I run out I end up back in the hospital”

From a blog on population health

…..success (in lowering healthcare costs and increasing quality of healthcare/better outcomes for patients) …will require the ability to embrace the messiness of disease and the complexity of patients, rather than providing idealized solutions that impress in the boardroom but flop in the examination.

It is refreshing not to have a wonkish campaign for the Republican nomination. Both 8 years ago and 4 years ago terms like “bending the cost curve” and “medical loss ratio” were being used by the actual candidates. Voters don’t want to hear that. They want common sense solutions for common sense problems. For healthcare, the answers are simple—after all, we’ve all been to the doctor, right? Make the sick folks make choices. Get ’em out and working. Since Dr Carson is, well, a doctor, his common sense answers are just the prescription for our sore ears.

As found here, he feels that Health Savings Accounts for almost all are just what the doctor ordered:

ObamaCare, he opines, is way too restricting. Why should people need to have the details of what they purchase?

A major problem is that many people in our entitlement society see nothing wrong with forcing others to provide for their desires. In a free and open society, anyone should be able to purchase anything they want that is legal.

Given enough freedom, the invisible hand will sort things out:

Most people will want to get the biggest bang for the buck and will independently seek out both value and quality. That, in turn, will bring all aspects of medicine into the free-market economic model, thus automatically having an ameliorating effect on pricing transparency and quality of outcomes.

In addition, the miracle of compound interest will overcome the human predisposition to become sicker as we get older:

If accounts are established at the time of birth, they will be even more potent because the vast majority of people will not experience catastrophic or even major medical events until well into adulthood. By that time, a great deal of money will have accumulated.

Lastly, Americans are generous to a fault and will contribute to a fund if it goes to those who are deserving:

The 5 percent of patients with complex pre-existing or acquired maladies would need to be taken care of through a different system, similar to Medicare and Medicaid, but informed by the many mistakes in those programs from which we can learn. Even this kind of system should have elements of personal responsibility woven into it.

Problem is, facts really get in the way of an attractive market-based narrative:

  1. Healthcare in this country costs about $8,000 annually for each man, woman, and child, of which the government currently pays around $5,000.- President Carson would put $2,000 into everyone’s account. Already he’s saved us money!
  2. Five percent of the population accounts for almost half (49 percent) of total health care expenses with most of those people being on Medicare or Medicaid.- Um, does that mean we bonus everyone $2,000 and then have to pay the same amount for folks on Medicare anyway? Or does their account magically grow? 
  3. The lower 50 percent of spenders accounted for 3 percent of the total national health care dollar.- Uh, oh, here’s a problem. We have taken this money out of health care and moved it into a savings account for healthy people.
  4. High spending persists over multiple years for many patients, while others return to more normal spending levels after an expensive episode. There is also evidence that high spending occurs near the end of life for many patients, particularly within the Medicare population- Well, this is a problem…what happens when the savings account runs out? I guess they are walking to the homeless food site.

Interestingly, Dr Carson performed operations that cost the patient’s insurance $3,000,000 on a routine basis. He never published his results, but the operation he became famous for (separation of twins joined at the head) apparently has a mortality of 50%, and an unknown but high rate of severe disability. It is clear that informed consent remains a real problem regarding outcomes without surgery. Since these operations occur in the first year of life, the twins could kick in the first $4,000 from their HSA. Wonder if having to collect $2,996,000 from the health savings accounts of 1498 of the parent’s closest friends and family would make a difference?

Me, I’m now into the Donald’s plan:

Trump said that the Affordable Care Act has “gotta go” and that he would repeal the law and replace it with “something terrific.”

2XL2100ZA: That depends on whether the light bulb has health insurance!

My wife has entered into the Obamacare fray on Facebook. The thread started with her disappointment on discovering that our mayor-elect had invited the “polarizing” Ben Carson to our fair city. Dr Carson, as you may or may not be aware, is a neurosurgeon who apparently is very technically skilled and, as it turns out, happens to be black. His personal beliefs have put him in the news recently. This is because he has gone around the country telling how his conservative Christian worldview (including views on homosexuality and evolution) has, in his view, allowed him to experience success. Our mayor-elect invited Dr Carson to tell his inspiring story at a fundraiser for a private, faith-based academy focused on helping poor, African-American children in one of the poorest cities (Prichard, 14th poorest city in the country) in one of the poorest states (Alabama) in the country. Dr Carson, since accepting the invitation, has made his views on health care for all citizens of our country pretty clear:

“I have to tell you, you know Obamacare is really, I think, the worst thing that has happened in this nation since slavery,” Carson said. “And it is slavery  in a way because it is making all of us subservient to the government.”

Carson, who is African American, went on to say that the administration’s push toward Obamacare is reminiscent to a push toward socialism.

“It was never about health care, it was about control,” Carson said. “That’s why when this administration took office it didn’t matter that the country was going off the cliff economically.  All forces were directed toward getting this legislation passed.

“Vladimir Lenin, one of the fathers of Socialism and Communism, said that socialized medicine is the keystone to the establishment of the socialist state,” he added.

So, as you might imagine, my wife’s initial concern, expressed to a Facebook group, about  our mayor-elect’s connecting himself with Dr. Carson has degenerated into an argument over health care as a right.

Given that Prichard, where the Academy resides, has 22,000 people, is 85% black, has a per capita income of $13,000, and has 0 physicians offices in the city limits, the free market doesn’t seem to have been serving them very well. I don’t want to get into a discussion of the reality that 1) someone has to pay for health care; 2) currently the money for caring for the poor being granted to the hospitals has left a city of 22.000 with no doctors; and 3) If the money follows the patient, as it does in Obamacare, isn’t that really the market at work?

Instead, I will respond to the proposition that doctors will simply refuse to accept lower rates from the new exchanges, which appeared in the thread. This is linked to the ongoing myth that “Doctors are leaving medicine in droves.” This was dealt with by The Incidental Economist several years back. Remember, the exchanges are an insurance product. Physicians can either choose to accept insurance or not. Medicare and Medicaid are also an insurance product, albeit with more strings attached. In the article they analyzed, 95% of primary care physicians were accepting new patients with 90% accepting new Medicare patients and 70% accepting new Medicaid and private insurance patients. This has been stable for several years. We physicians have a symbiotic relationship with insurance companies that is not likely to be severed soon.

Many people believe (or want to believe) that concierge practices are a way out of the physician-insurance nightmare. In these practices, physicians eschew all insurance and instead limit the number of patients they care for (typically 600 or so) and charge a retainer not covered by insurance (anywhere between $40 and $400 per month). The advantage to the patient is the doctor’s cell number and unfettered access. Ever wake up in the middle of the night with a nagging cramp? Husband not sympathetic? Call the doc… Advantages for the doctor are less administrative overhead (insurace filings pushed to the patient). Conrad Murray was the ultimate concierge doc, charging Michael Jackson $150,000 per month, but the price was a little steep for both of them. Mostly, when docs shift to concierge practice, 88% of their patients leave. Currently about 50 such practices exist in the country, so while many physicians see it as an out, it is likely a limited career path.

What do I think is going to happen? I believe that, assuming the markets don’t tank, physicians over 62 or so will likely retire. This is more because of the electronic health record requirements than Obama-Lenin-care, which I don’t see the government backing away from. I think that those folks coming out of residency will adjust just fine. I think a lot of people from ages 45-55 who have planned for an income that is unachievable in a health care environment that no longer exists need to read “Who Moved My Cheese.”

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