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...

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