Tuesday, May 26, 2015


Life flows from warmth to a chill but sometime the chill can get sandwiched between the warmth, like a low pressure between two highs and stay stationary, as in this case; a patient caught between the extremes of human-created double jeopardy- between a hospital and a rehabilitation center.

A fellow I know lived an active life. He happened to find the unfortunate uneven step on the roadside that felled him onto a concrete slab. The slab was not hurt but the man’s skin needed the eye of the needle as it thread through some layers of epidermis and a staple gun to keep the thicker gashes closed. With repaired bones, stitched and stapled skin he went on to receive inpatient rehabilitative services in a facility that boasted the best services in town. “Living healthier lives” the banner claimed.
Unrelated image from Internet 

The facility was clean, almost immaculate; starch white floors with rubberized marked walking paths in its hallways, food served on glassy clean trays, and all care givers dressed in pure white. The only thing that marred the white was an occasional black stethoscope draped around the neck. The plenary focus seemed to impress and exude cleanliness a virtue of godliness as a means to faster, quicker and better recovery from the ill-gotten misfortunes of living impetuously. 

Yet in almost a whisper the hallways had a story to tell, a strange one at that. None of the infirmed denizens of this famed and storied facility seemed to be bipedal. They were all rolling along in their wheelchairs. Some with their legs firmly planted on the foot rests and others with one or both sticking out in front like the bow of the boat parting the air at any obstruction in front for careful clean passage.

The personnel seemed happy and cheerful. The infirmed seemed content too. This did seem like a Shangri-La of rehab facilities after all, just as advertised. Or was it?

I asked…

“How come, none of the patients were ambulatory?”

That caught the woman in the white starched uniform by surprise. “Ah, well, when they are ambulatory, we discharge them.” She replied with an imprint of discomfort in her voice .
Wow, I thought…what a concept of rehab. Bring the patient to the edge of their ambulatory ability and boom, ‘off you go!’

I learnt the secret later from a slightly verbose worker, “Well you see,” he opined as his head turned to look quickly at both sides like Regan in The Exorcist, “we do not want anyone to fall accidentally and hurt themselves. So we have a strict policy to allow full ambulation in the rehab rooms when they are with the therapists, that way, no fall, no lawsuits!” He finished.

“How long do most of the patients stay in the facility?” I asked.

“Oh, anywhere from two to four weeks,” he replied.

“And how many hours of therapy does each patient get?”

“Usually the therapy lasts 45 minutes, because most tire quickly and that is twice a day on alternate days otherwise once a day.”

“The rest of the time…”

“They are in their rooms in bed, being monitored by closed circuit TVs. If they need to go to the bathroom or shower they are given full assistance.” He smiled, “after all, safety is no accident, is our motto!” He added, “Keeps the lawyers away!”

So here was care driven through the eyes of the policy-makers with one eye on litigation risk, and the other on padding the bottom-line rather than true benefit of patient’s care. The staff was happy and well paid and the patients were content, watching TV and being served with no effort required. The only thing missing was real advancement in the patient’s abilities. One might wonder how many of these “discharged patients" would find their way back to the hospitals from falls related to atrophied skills. But those statistics are difficult to come by. Those statistics are only meaningful in readmission rates. So why not rehab the stitched patients for 4 weeks and then discharge. Ah the cynic in me is loath to deliver the benefit of doubt easily.

Rehabilitation 2.0 is the nuanced version of dotting the “I”s and crossing the “T”s for reimbursement checks, for longer duration of stays and for confining the patients from progressing rapidly towards optimal health. Place the metric in the wrong cubicle and what you will get is more quantified nonsense. But it makes people happy! It makes the deliverers of such care wealthy and it makes the pundits gloat with certainty how they have “streamlined” the system for outcomes.

What a system the system has spawned!

Sunday, May 17, 2015


A curious idea came into my head the other day. A concept, really, as it  furnished itself into a full blown thesis. You might ask what the thesis was about. That…

Man is meant to fly!

Looking at those creatures that take flight under their own power, the answer would be no. Man therefore was not meant to fly. That then is the original antithesis.

Yet when I look at the airplanes, man has learnt to utilize material to allow himself to fly through the air. True that! And recently the Jetmen who flew over Dubai, suggests that man is coming closer to the original hypothesis of man is meant to fly. This then is the new synthesis.

The dialectic proceeds and furthers our notion that we as humans go boldly “there” wherever “there” is because it is there. The original thesis continues to be reframed by the antithesis. The mind forces the world and brings it to its knees. Space and time are forced through the dialectic of a mind into substance and causality. And eventually the antithesis reforms the original thesis; “Man is meant to fly but with an assist!” This might change in the future, since there are antithetical arguments already in place to re-synthesize the newly reformed thesis.

The universal paradigm of giving birth to a thesis also leaves a constant trail of evocative pebbles in its wake. Not every concept takes flight after all. Each pebble a “run in with the antithetical monster,” is a constant reminder of how the world is shaped. Each pebble an outcast, lost in the whirlwind of the antithetical argument, never to realize its goal. In golf there is a truism about putting, “Not up, not in.” That is true for the discarded pebbles in the trail of a shaped reality. One such fresh pebble lies behind our last footstep, forced by the antithetical force of truth and finds itself heaped in the basket of ruined thought.

This thesis that lies bleeding, by a thousand cuts, is the Maintenance of Certification (MOC) requirement for physicians. Here the thesis propounds some fallible arguments pitched only by the conflicted souls of the organization. The originators of the MOC, ABIM/ABMS, claim there is a need for MOC and the importance of MOC is for the benefits of the patient care; public good is implied. Hidden, but recently revealed, is that there is no benefit to either the patient or the physician from MOC compliance, except only to the agency (the ABIM/ABMS), that collects millions of dollars in fees pays the officers handsomely in 7-figures and then plows the remainder into the ABIM Foundation.

The thesis suffers another deadly and paralyzing blow when it is revealed that the chief and pilot reason for this thesis to take shape in its current manifest form is to rake in money to avoid the organization from falling into the abyss of bankruptcy. Meanwhile, the money flows from the guileless physicians and the system lavishes itself with the royalties from the same distracted, confused and easily persuaded group under the guise of “do no harm.” Ah the muddied waters get muddier by the hour. The blows are many and the MOC’s outstretched limb for regulatory help might be a bit late to resurrect its image of a once beloved and dedicated organization. Indeed money has re-framed the shiny robe into a moth-eaten fabric of greed. The environment has decayed, ripe and teeming with the entozoon.

The only correlate that I can find to the MOC phenomenon is a malignant leukemic cell that thrives in its micro-environment where it is fed by supporting cast of other like-minded cells to prosper and proliferate at the detriment of the host. Sad but true. That is the Yin and Yang of life. To kill the beast or perish under its weight.

The antithetical argument to MOC seems to have found its stride. MOC was never meant to be helpful to the patients and their physicians - this much is well established. The original tenet was faulty! The antithesis is robust. Hence no synthesis is possible. A human response antidote is needed. The dialectic is fractured. The vein of fiction is ruptured and the vessel exsanguinated. There is no life to support here. The EKG is flat lined! No breath, no pulse, nothing! The thesis is dead! 

Move on!

But, “No,” say the enriched tarnished brass pining for the polish to shine, “The MOC is dead. Long live the MOC.” Apparently the new/old thesis has not been fully realized by the players yet. The old verified and validated thesis being, “CME is still king.” NBPAS (National Board of Physicians and Surgeons) seems to understand that very well and so do most 97% of the physicians (based on a SERMO survey).

“Move On!” 

Wednesday, May 13, 2015


There is an interesting play that is playing out in front of our eyes. It is quite provocative and stealthy. It is filled with all sorts of assumptions and the players are well dressed in expensive costumes. The play is being staged in every Main Street America. The players strut their stuff as the Tchaikovsky 1812 Overture plays in the background. You can spot the stagehand peering beneath the curtains looking at the audience reactions. His eyes appear and disappear through the course and simultaneously the players direct their attention to a specific segment of the audience. The undercurrent in that attention is a warning to stay quiet, be attentive and follow the discipline of proper public discourse.

Let us make some substitutions: The patients and doctors for the audience and the Bureaucrats and Authoritarians for the Players. And now imagine the Playwright standing with his bejeweled hands folded at the entrance to the stage. His unscrupulous eyes darting this way and that looking for any displeasure that the audience might register and turning into slits with pleasure as the audience claps its approval.  His Cheshire cat like smile is both radiant and visible to the pleasure of his players. Some of his actions are teasing, some tortuous, some monstrous and some evil. Like mathematics for most, his musings are irrationally caged in obscure symbols and drive his desires with help from the willing. It is in this style and the proofs rendered that the character of this maestro shows, couched in euphemisms, evoking images of empathy yet holding the glare of dogma and detriment.

Okay now to reality…

If you haven’t yet noticed, bet this will get more than a silent response: the current zeitgeist in the U.S. is to vilify the doctors. The daily headlines declare that the healthcare costs are burdening the society and account for 17.9% of the GDP. And you say to yourself, Hmm that is true! The next headline suggests that the Doctors should “Choose Wisely” in their diagnostic and therapeutic endeavors. The implication of course is that doctors don’t. The other new bandwidth that is being stretched to carry their messaging is that Medicare will now pay only for “Quality care.” Again implied therein is that patients do not get quality. And here the real kicker is how does one define quality? There are no hard or soft metrics to determine quality unless one considers ONLY the cost of rendered care. If you have not tuned into the “2012 Data Dump” that clearly showed that the doctors were direct paid $77 Billion that year from CMS expense of nearly $1 Trillion ($1,000,000,000,000.00), take into account that there are 850,000 physicians that were paid for their services, which included their overhead costs. If you have a calculator handy, that, translates to $90,588 per physician. So on the one hand the talking heads are railing over the costs and pointing fingers at the physicians and yet the reality is quite different. Isn’t it? Where is the rest of the expensed money? That’s an easy one to answer… Administrative expenses, “Hospital-facility” care, Pharmaceutical and Device costs of course! "While the AIDS Healthcare Foundation has criticized the price of Solvadi treatment—$84,000 for 12 weeks, $168,000 for 24 weeks—two Leerink Swann analysts said in a note to investors the cost was comparable to the other treatments, citing in part the $66,000, 12-week cost of Olysio, and $100,000 for an eight-week combination of Solvadi and Olysio." Don't forget, there is a price for innovation in there too...

...but none here except...make plans to take money

When some physicians start talking about Fee-For-Service (FFS) as in Concierge Medicine, the pundits descend on them like vultures calling them “greedy doctors.” These pundits continue to trawl the waters, with nuclear device carrying nets, for planktons. But don’t you think, costs can be best contained when the buyer and seller of a service are equally involved in the contract?

Perhaps, only when one sees the human affairs from a distance can one see the convention behind them… For the Rulers, their proof glides smoothly over the water as the turbulence from the webbed feet below the surface creates giant eddies trying mightily to throw the planktons into a vortex of confusion.

Then, there are the horns of this dilemma pointing south to real greed and wealth. On the south side is the new found love of having care provided at the CVS, Walgreens and Walmart retail stores. The difference is that in these locales one has to fork out their cash. No insurance payments required. There is no greed there? I am of the Austrian persuasion; win only through a better product and service, not another's destruction.  By the way In the case of Walgreen Co. (NYSE: WAG) the market cap is now $70.44 billion and is #63 in all time high market capitalized firms in the world. http://www.forbes.com/sites/dividendchannel/2014/12/12/walgreen-moves-up-in-market-cap-rank-passing-ebay/  Whereas for the CVS Pharmacy and now CVS Health the market capitalization is $113.4 Billion. No small change, you would agree. (NYSE: CVS)
http://www.wikinvest.com/stock/CVS_Caremark_Corporation_%28CVS%29/Data/Market_Capitalization Walmart market cap should you wish to know is around $261 Billion. Good for them, but...
Most would say, well they are retailers and provide services. Umm, yes they do, but so do physicians who care for their patients and do not engage in retail sales, yet are demonized daily. Apparently these retail riches from healthcare don’t seem to bother the policy makers as they pump the dollars in their direction while heralding the new era of cheaper healthcare and simultaneously vilifying physicians. Oh by the way did I mention that the “providers” at these retail facilities are mostly non-physicians, who man their health centers and are free to write prescriptions, without a medical license that the in-house Pharmacists are glad to fill. Is there a conflict of interest here? No! …Most will say… Really? Guess there are a lot of pin-striped suits, from K street, with pockets filled with lobby money that walk the halls. CVS Health for instance, spent $14,787,646.00 in lobbying Congress in 2104. Hmm. https://www.opensecrets.org/lobby/top.php?showYear=2014indexType=s
And if you count, 6 of the top 20 lobbyists in Congress are related to healthcare. The Quid in this is definitely for the Pro to carry to the Quo! Bring this up and their answer will be “We are making a Yeoman’s herculean effort in providing the ‘right’ kind of care that America needs.” Huh? The shades of National Health System in the United Kingdom come crawling to the mind, as the image of burning fetuses to warm the hospitals run through the mind. http://www.telegraph.co.uk/news/health/news/10717566/Aborted-babies-incinerated-to-heat-UK-hospitals.html

Seriously, there is something out of frame. The context of reality is buried deep within Bills, Guidelines, Mandates that no one reads and everyone, lazy as they are in the government, assumes and the talking heads vocalize and the gentry’ signs on. Meanwhile patient care suffers due to denied care. Physician health suffers from early depression and high rates of suicides. Universal morals and morality decline. Substandard values take precedence. The rhetoric continues because the rulers and makers of rules have little care except for control and command. They have little worries for they will be provided with the best staffed hospitals and the most dedicated staff to care for their pinky when it gets scraped.

It is possible that the lost habit of the laity’s concentration will be replaced by the eyes of their spirit and the virtues of their needs, someday. But these are the days of unguessed configurations, unknown unknowns, uncertain futures, unglued tautologies that sneer at all of us. It might be time to hang the image in the frame correctly.

How this play will end, one can only guess. 

Meanwhile, Tchaikovsky’s symphony, with canons blazing, plays on…

Time to Wake up America.

Saturday, May 9, 2015

10 PRINCIPLES to live by.

Life is short!

1.       Live it! Make time for things that you desire to do. Read and learn from those much smarter than you. Paint what strikes your inner fancy. Write the words that have wanted to come out. Tell a story. Plant a flower. Create an industry. Channel your inner child. Look at things differently. Change your perspective. Play a musical instrument. Listen to music. Close your eyes and dream. Work hard. Be Productive. Reach for the moon and the stars. Above all, Enjoy your Family and Friends!

2.       Smile! Lose the frown lines. Develop the crow feet. Laugh often over something or nothing at all. Find contentment within yourself. Express yourself. Forgive, but do not forget. Learn from your mistakes. Cultivate human interaction. Touch a shoulder. Shake a hand. Look into eyes. Show those dimples. Surround yourself with friends. Enjoy another’s company.

3.       Keep Healthy! Eat light. Keep a little hunger. Do not satiate. Exercise. Walk. Run. Ride a bicycle. Ski. Golf. Swim. Do not Smoke. Avoid alcohol. Avoid the “Take a Pill” culture. Spend time outdoors. Smell and feel the fresh air. Create a new path. Follow a trail. Choose. Occasionally fast for better immunity.

4.       Trust! Always verify. Do not fall in love with words. See the person. Ask questions. Analyze answers. Think and rethink. Look at deeds. Listen to their personal character descriptions. Find the truth in their souls. Match their words to their actions.Validate the trust through verification…Always.

5.       Critically think! Listen. Analyze. Use your knowledge. Merge dimensions. Do not rationalize. Do not give credence without objectivity. Understand the motive. Understand your bias. Reason.

6.       Find the Evidence! From C/O > HG > PS₁ > EE₁ > PS₂ > EE₂ > RE > V
a.       C/O        Concept/ Observation
b.      HG          Hypothesis Generation
c.       PS₁          Problem Solving (initial)
d.      EE₁          Experimental Evidence (initial)
e.      PS₂         Problem Solving (subsequent)
f.        EE₂          Experimental Evidence (subsequent)
g.       RE           Experiment Repeat-ability
h.      V             Validation.

7.       Beware of Statistics! Use numbers. Careful with percentages. Be wary of contrived graphs. Be wary of Confidence Intervals, Hazard Ratios, p-values, Regression analyses, Logit. Contrived data will cloud intuition. Be wary of small number statistics. Be wary of the hyperbole. Do your own simple math. Do your own analysis. Use your personal experience to interpret. Use simple Logic.

8.       Be wary of Words! Language is for expression and understanding. Be wary of hyperbole and difficult words. Use simple words. Use context. Do not complicate. Do not use complexity. Explain with concision.

9.       If it is too good to be true? Then it is! Nothing is for Free. Someone always pays. Carry your own weight. Do not be obligated. Do not be dependent. Do not abrogate your responsibility. Do not be a ward. Do not “take it.” Do not accept a wrong.

1.   Morality! Tell the truth-you don"t have to make up stories (lies) to tell it. Be self-deprecating. Be kind. Be thoughtful. Do not laugh at another’s expense. Be considerate
. Put yourself in other’s shoes. Weather the storms do not broadcast them. Be humble. Do not impose upon others.

That ancient silent oak of Reason stands tall overseeing the valley of flowers that bloom and decay with time.

Tuesday, May 5, 2015


…and the value of nothing” – Oscar Wilde

Rip Van Winkle just woke up. Gone were the bucolic vistas of yesteryear. There are skyscraping glass enclosed buildings that obscure the horizon. Gone were the quiet, empty streets replaced with cars of all shapes and sizes humming through above the speed limits. Gone were the bakery merchants chatting with community friends outside their businesses, now they hide behind steel bars that protect the window panes and their lives from the street demonstrations.

Things have changed, Rip.

Where is the value in living, Rip wonders?

Value is an easily defined term in inanimate products and has at its core embedded within quality. And equally quality is an easily definable term in inanimate products. When quality is reduced, the value to the consumer is reduced proportionally; a 1:1 ratio exists between the two. So now we add a new term in our thought experiment: consumer. One can safely say then that the “value” to the consumer is based on the “quality, function and reliability” of the product purchased.

What happens when the producer cheapens the quality by using substandard material? The consumer initially gets duped and then fires back by voicing his or her opinion and reversing loyalty. The loss is felt by the producer whose fortunes decline from loss of sales.

The “planned obsolescence” by American Automakers forcing the consumers to buy new cars every five or so years hurt Detroit in the long run. The city is in ruins from the excesses and demands of the past. The Japanese quality emerged as the new norm overtaking the American auto paradigm. The time arrow flew and subsequently some automakers calculated risk losses from poor engineering vs. the price tag of a mass recall and allowed for the potential unmitigated risk to flow straight to the consumer, leading to eventual bad press, loss of confidence and consumer base contraction, again leading to trust-collapse.

Sometime the advancement in engineering and new value predates the social culture and companies have been known to falter for not realizing those dynamics. The classic example is Apple Computer which brought forth the Lisa computer that failed, a Newton that failed sending the company into a free fall. The latter was resurrected as an iPad and Apple is on top once again with a $700 Billion market cap. Here the product was never in question, just the timing and its value to an uninitiated customer..
So value is in the eye of the consuming beholder!

Consider this, if you paid for an orange and got a lemon. What would your reaction be? You would want your money back, Right? As it should be! Now let us look at it another way. If you paid for an orange and got an orange but decided you wanted a lemon then the only way to get your money back would be to either own up to your fault or if you were lacking in some basic morals, turn against the seller.

Congratulations Rip, you have arrived on the modern landscape! It is the year 2015 and everything has a price on it!
Consumers buy clothes, wear them to parties with the price tags hidden inside and then return them back for a full refund to the seller. Is this right? Depending on how many you have returned, most would say categorically it is wrong. Yet returns in businesses are a fact of life and are computed in their income statements and balance sheets. Everyone calls it the “Cost of doing business.” But what is the cost to the psyche of such a society, whose fabric gets ripped just a little more? No one knows, because these behaviors remain hidden under the pretext of consumer sentiments and other such politically correct niceties, espoused by the politics and the family culture at home.

The measure however does rear its ugly head in the form, of demands for free this and that. Entitlements are a growing scourge of the evolved modern human element and continue to eat away at the national wealth of the State.

Just like business and mostly because of business-minded administrators that have infiltrated medicine, there is a call for value in medical care. So the question is ripe for the asking; what constitutes value in medicine? You might say “access,” or “cure from an ailment” or “acquiescing to the demand of the patient for antibiotics or pain killers” or even “not having any future illnesses.”
These are all very formidable hurdles in reality. 

“Access” to care is the easiest and has been solved for decades in the United States. No person was denied healthcare in the United States if he or she showed up to an Emergency Department with an ailment. This has nothing to do with “Insurance coverage” policies now in vogue.

The second issue is more difficult. Curing a disease is based on the nature of the disease. If it is a bacterial illness that is amenable to an antibiotic, well then yes. But if it is a late stage cancer then the impossibility remains. So if you as a physician are unable to cure a person of his or her cancer, are you then not providing “value” to the patient? Are you therefore a bad physician? Similarly treating type II diabetes is largely a function on following directions of diet, exercise and medicine to control the blood sugar. You as a physician might spin all the wheels with education and medicines but if the patient is non-compliant, eats donuts all day and drinks sugary drinks all night, how can that bring in the hallowed outcomes? Where is the value in that?

The third issue of acquiescence to patient demands is a human-human barter deal in today’s world. If you as a physician do not give in to the demands of prescribing an antibiotic for a viral syndrome to appease the patient’s sense of “getting something done for the cold” then you are berated in the satisfaction scores equally if you don’t prescribe the pain-killers to those who desire them but shouldn’t have them. Since the consumer, here the patient, is in command and you the physician, the medical care giver, are completely under the consumer’s will to bend and shake till you agree to those demands, the social media reckoning is upon us for good or worse. Is this the “patient-centric” care? 

The fourth issue of prevention is being forced onto the physician. Not preventing a “preventable illness” leads to bad outcomes and becomes a direct result of poor patient care. The Readmission policy presently in vogue that denies reimbursement to hospitals for patient readmission for similar illness or infection is a case in point. Poor immunity is a gateway for multiple infections. A person in poor health has poor immunity; hence the re-admissions unfortunately are a way of life, but not to the experts in the ivory towers. Do these policies have real metrics in place? If not then it is just a means to control costs and deny appropriate payments for services rendered. In the business world one can litigate. In the medical world, one walks with the tail between their legs. And all the while the experts pushing value based payments state, “Moving to Value Based Payment along the timelines [suggested by the state] while incredibly ambitious is aspirational,” said Sean Doolan, chair of Hinnman Straub's government relations department. Just read the two words, “ambitious” and “aspirational.” My question is for whom are these words intended? One should wonder, is it not also the responsibility of the patient to exercise self-care? Or is the patient so infantilized that he or she does not know that smoking, eating indiscriminately, obesity sedentary lifestyle and drinking in excess will lead to ill health? Must doctors now know and divulge personal information related to their household finances and gun ownership to the insurer? The grim monologue from the insurers seems to suggest yes they must.

Speaking of the Value everyone is yammering about, here is what  Stephen Berger, chairman and founder of Odyssey Investment Partners, L.L.C., a private equity firm, and chairman of the New York State Commission on Health Care Facilities in the 21st Century had to say, “I don't know where 'there' is. And I think there is not one 'there.' There is a lot of 'theres,' and I'm concerned that a great deal of what we are counting on depends upon being able to have some more clear discussable, understandable definitions of things like quality.” He went on to say, “I see no evidence that that will produce the kinds of dollars we need to support the safety-net network and the delivery of care to all the people we want to deliver it to at a higher level of quality,” he said. “That, at the moment, is more an issue of belief and hope than something I can see analytically.” Oh, I can see clearly now that the rain has gone… Although Mr. Berger’s vision remained clouded a bit too, "We have to understand how much chaos we are going to be creating to get to some place better.”

Meanwhile the N.Y. state Medicaid director Jason Helgerson said, "That is a great start," Helgerson told Capital in an email. "We have heard from a number of providers who want to do even more."  Who, pray tell are these providers? He went on to say, The Value Based Roadmap, which outlines how this transformation will occur, will push, Helgerson said, and "Medicaid will focus mostly on carrots but we will use sticks if necessary." Does anyone feel the heat here?

But let that not perturb you because another believer states,  “Hard to say [you're] not for 'value-based payments'—it's like motherhood and apple pie,” said Valerie Grey, executive vice president of policy for Healthcare Association of New York State. The overarching question then is, Who is the Consumer...the Insurer, Bureaucrat-Administrator or the patient?

Oh dear Rip, sorry you woke up so soon and not sooner.

You see when the price of everything is known, the value of everything suffers. Cutting costs leads to cutting corners, leads to denials of care, leads to a many-headed beast that devours all in its wake or like Medusa's head that blinds one to reality.

So our minds are corrupted and we are blinded to...