RECONCILE
rec·on·cile
ˈrekənˌsīl/
verb
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.
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.
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.
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?
ONLINE REFERENCES:
At some point, a bit of intellectual reconciliation might be a good idea! Don't you think?
ONLINE REFERENCES: