Sunday, July 2, 2017



make (one account) consistent with another,

In business, the act of reconciliation of revenue and expenses is done on a periodic and timely manner. In medicine this is perhaps never done. Each silo stands on its own foundation and power structure, so much so that it becomes an entity to itself. Legions of intellectuals then profit from their fame by using just the right amount of information to fold their personal needs.

That nagging prickly itch, has always confounded my sense of quiet, when I look at graphs dominating the universe of healthcare disparity among nations. Something is amiss.

Often in the light of day, a graph will present itself by a notable to evoke a sense of something in the observer. That something, is the subject of this discourse.

On the face of it, it does look damning. Wow, one wonders, the United States, the wealthiest of nations spends so much in healthcare and gets back so little in return compared to all the other industrialized nations in the world. Ivory tower experts and politicians have often resorted to using these graphs at their various forums to articulate an idea, a policy or a mandate. The elites choke on their finger-food at the sight of this graph. “How can that be?” they gasp.

So, in the act of this reconciliation, let us also put this graph up. Now this one makes the physician community raise their fists. They may have a point, if one considers this in the realm of expenses alone for just a moment. If you look at the administrative burden imposed on healthcare starting in 1979 one begins to wonder whether the expenses incurred were directly in relation to physician patient care or some other gnarly rudiment of an established order that has wormed its way into medicine? Perhaps there is the invisible Maxwell’s Demon at play here?

Hospitals that are allotted 36% of every Dollar expensed in healthcare seem to have an overtly large fount of administrative costs and that is ever increasing. There are many reasons for that including the Managerial 7-figure salaries but there are arcane policies and mandates rained down from the governmental and policy expert heavens as well. For example, in the modern-day hospital, there are more non-nursing nurses walking around with pads and pencils than there are care-giving ones that get their gloves dirty. There are legions of non-physician infectious disease experts, oncology experts, cardiology experts, Reimbursement experts, Social Service experts, Patient safety experts etc. who walk the floor speaking in hushed voices of technical importance but never lay their finger on the patient.

But you might say, “Ok, the graphs are provocative and I can understand that administrative costs have raised the healthcare expense, but what about the longevity issue?” Yes, my dear Watson (Not the IBM kind) there is a story in that as well and we shall take that slowly and perhaps step by step.

There is a grafted nuance conflating variables that have no need to be cohabitated in a graph unless one wants to write a provocative piece on “correlation.” And lo and behold that is exactly what we get most of the time. Just for a chuckle one might ask the question, “What does longevity have to do with healthcare?” The experts will propound with deep Darth Vader type hiss, “Because death is avoided by good healthcare.” Really? Wouldn’t one think of other reasons just for the sake of an argument? You know, like lifestyle and behavior?

The most ideologically touted reasons for decreased longevity is Maternal mortality, Infant mortality, death by firearms and obesity. Most of the time in that order.

"In the United States the Maternal Mortality numbers are around 12/100,000 live births. In 2015, there were 3,978,497 births thus the total maternal mortality would be: 477 maternal deaths. On the infant mortality side the numbers are 6.1/100,000 and that would translate to 242 deaths in the same year. Total firearm related deaths in 2015 came in at 13,286. Now one might want to keep that in perspective especially with a population of 312,000,000."

Ah some might say that is heartless, “There should be zero deaths, given such a wealthy country! We must avoid all human deaths especially the little babies and vulnerable women.” Yes, I guess we should try to, but humans are humans and not robots, last time I checked.

But that still does not answer the question why the longevity in the US lags other “Industrialized nations.” Does it? So, let us take that discussion a bit further. Using the last bit of “reason” that experts give, let us look at “Obesity.”

Global OBESITY Chart (hi=Redness)

As is well known to most physicians and thinking humans around the world, obesity is a chronic disease state. The metabolic effects of Obesity cause Type II Diabetes Mellitus and many organs to fail, among them, the heart (higher numbers of heart attacks), the brain (Higher numbers of stroke), the kidney (Higher incidence of kidney failure), the eyes (Blindness), Peripheral Arteries (Vascular ischemia gangrene), Immunity (More Infections and risk of septicemia). Perhaps it is time to look at Obesity as the culprit. Wealthy countries have an epidemic of Obesity. The definition of poverty is fluid so one needs to be careful in assessing that particular-variable. For example, in the deserts of Africa and war strewn middle eastern nations Obesity is non-existent because of lack of food and the safety net. Meanwhile in wealthy nations where Food stamps (SNAP) and other such public beneficence is available, obesity is rampant. There is evidence of the association between sedentariness, poor health, obesity, diabetes, other metabolic diseases, and premature death. Thorp et al. state, “There is evidence of the association between sedentariness, poor health, obesity, diabetes, other metabolic diseases, and premature death.”
Thorp  AA, Owen  N, Neuhaus  M, Dunstan  DW. Sedentary behaviors and subsequent health outcomes in adults a systematic review of longitudinal studies, 1996-2011. Am J Prev Med 2011;41:207–215

Another worthwhile thing to mention is the infant birth weight that seems to be diminishing as feelings of "body dysmorphia" syndrome continues to wax (I admit there might be conflation here, it also might be nutritional intake voluntary or involuntary). Doesn't seem to help the infant survival either in the well developed industrialized nations.

If we are to agree that obesity is an epidemic in most wealthy civilized societies then one would construe that longevity is also compromised. Comparing obesity charts, it appears that the United States has a 36% obesity rate (defined as BMI >=30). Sweden on the other hand has an obesity rate of 10%. Now putting the two figures together one can easily make the link between Obesity, Type II Diabetes and shortened life span due to the inherent morbidities. It is not that the US has poor healthcare. It is that a sizable segment of population has chosen a life style of excess food intake and a sedentariness that provokes the “untimely frost.” The CDC makes a case, “The U.S. is one of the wealthiest countries in the world and accordingly has high obesity rates; one-third of the population has obesity plus another third is overweight. The situation is predicted to worsen; rising childhood obesity rates forewarn of worsening statistics.”

A lifestyle choice that brings with untold misery to the human body and shortens longevity is not by any means related in any way to healthcare itself, if one were to use a tincture of reason. Is it?

In “Cool Hand Luke” the Captain states, “What we have here is a failure to Communicate” correctly, methinks.

Tying together Taxes to healthcare and thus longevity is a simpleton’s mechanism to obfuscate the truth it seems. The expert’s wheel barrow with square wheels continues to noisily hurtle down the road and no one questions the wheel or what’s in that barrow? The noise is deafening and all encompassing. The experts maintain in-spite-of the evidence available, “They note the U.S. also has the highest homicide rate, the highest rates for obesity and overweight, and the highest rates of mother and child deaths of all high-income nations.” In their own right, these statements are true but not if one conflates them with the expense of healthcare. The EU citizens pay astronomical taxes via Income Tax, VAT and a host of other consumption variety of taxes. For example, a real tax rate of 57.53%, France topped the list in 2016. In the UK, the 45% top rate of tax kicks in at an income level of around $250,000, while the Outside the G20, the Danish government taxes workers at 60% on all earnings over $60,000. Apparently, the love of the government runs deep in the veins of those European souls. On the U.S. shores, experts and policy-makers conversely, “suggest large inequalities and lack of universal health care are among the reasons the U.S. is falling behind,” without any real evidence or making rational deductions based on the evidence easily available to the curious.

As has been the case and will be for sometime to come, The costs are then shifted at the feet of the physician. And evidence of that comes when a complexity of systems is brought to bear in the form of P4P, PQRS, MACRA, MIPS etc. These are nothing more than attempts at controlling the healthcare costs by squeezing the physicians. But what evades these experts is that physicians make between 7% based on the 2012 Physician Data Dump and 9% based on experts. Or in simplified terms physicians make 7 cents on every dollar spent on healthcare and that includes all the costs of having a medical practice, employees, supplies etc. Or in business terms the fixed and variable costs. The largesse accumulated by the other “providers” is mostly ignored because of the intense lobbying efforts by the Hospital Association, The Insurers, The Pharma, The Pharmacy Benefit Managers, The IT gurus like EPIC and CERNER. Willful blindness seems to work well in the Halls of Power.

At some point, a bit of intellectual reconciliation might be a good idea! Don't you think?