1. Featured Article:
The Morality of Admitting so many Students to Classes they cannot Pass
Atlantic
Monthly June 2008
In the Basement of the Ivory Tower by Professor X
The idea that a university education is
for everyone is a destructive myth. An instructor at a "college of last
resort" explains why.
I work part-time in the
evenings as an adjunct instructor of English. I teach two courses, Introduction
to College Writing (English 101) and Introduction to College Literature
(English 102), at a small private college and at a community college. The
campuses are physically lovely - quiet havens of ornate stonework and columns,
Gothic Revival archways, sweeping quads, and tidy Victorian scalloping.
Students chat or examine their cell phones or study languidly under spreading
trees. Balls click faintly against bats on the athletic fields. Inside the arts
and humanities building, my students and I discuss Shakespeare, Dubliners,
poetic rhythms, and Edward Said. We might seem, at first glance, to be enacting
some sort of college idyll. We could be at Harvard. But this is not Harvard,
and our classes are no idyll. Beneath the surface of this serene and scholarly
mise-en-scène roil waters of frustration and bad feeling, for these colleges
teem with students who are in over their heads.
I work at colleges of last resort. For
many of my students, college was not a goal they spent years preparing for, but
a place they landed in. Those I teach don't come up in the debates about
adolescent overachievers and cutthroat college admissions. Mine are the
students whose applications show indifferent grades and have blank spaces where
the extracurricular activities would go. They chose their college based not on
the U.S. News & World Report rankings but on MapQuest; in their
ideal academic geometry, college is located at a convenient spot between work
and home. I can relate, for it was exactly this line of thinking that dictated
where I sent my teaching résumé.
Some of their high-school transcripts are
newly minted, others decades old. Many of my students have returned to college
after some manner of life interregnum: a year or two of post-high-school
dissolution, or a large swath of simple middle-class existence, 20 years of the
demands of home and family. They work during the day and come to class in the
evenings. I teach young men who must amass a certain number of credits before
they can become police officers or state troopers, lower-echelon health-care
workers who need credits to qualify for raises, and municipal employees who
require college-level certification to advance at work.
My students take English 101 and English
102 not because they want to but because they must. Both colleges I teach at
require that all students, no matter what their majors or career objectives,
pass these two courses. For many of my students, this is difficult. Some of the
young guys, the police-officers-to-be, have wonderfully open faces across which
play their every passing emotion, and when we start reading "Araby"
or "Barn Burning," their boredom quickly becomes apparent. They
fidget; they prop their heads on their arms; they yawn and sometimes appear to
grimace in pain, as though they had been tasered. Their eyes implore: How
could you do this to me?
The goal of English 101 is to instruct
students in the sort of expository writing that theoretically will be required
across the curriculum. My students must venture the compare-and-contrast paper,
the argument paper, the process-analysis paper (which explains how some action
is performed - as a lab report might), and the dreaded research paper, complete
with parenthetical citations and a listing of works cited, all in Modern
Language Association format. In 102, we read short stories, poetry, and Hamlet,
and we take several stabs at the only writing more dreaded than the research
paper: the absolutely despised Writing About Literature.
Class time passes in a flash - for me,
anyway, if not always for my students. I love trying to convey to a class my
passion for literature, or the immense satisfaction a writer can feel when he
or she nails a point. When I am at my best, and the students are in an
attentive mood - generally, early in the semester - the room crackles with
positive energy. Even the cops-to-be feel driven to succeed in the class, to
read and love the great books, to explore potent themes, to write well.
The bursting of our collective bubble comes
quickly. A few weeks into the semester, the students must start actually
writing papers, and I must start grading them. Despite my enthusiasm, despite
their thoughtful nods of agreement and what I have interpreted as moments of
clarity, it turns out that in many cases it has all come to naught.
Remarkably few of my students can do well
in these classes. Students routinely fail; some fail multiple times, and some
will never pass, because they cannot write a coherent sentence.
In each of my courses, we discuss thesis
statements and topic sentences, the need for precision in vocabulary, why
economy of language is desirable, what constitutes a compelling subject. I
explain, I give examples, I cheerlead, I cajole, but each evening, when the
class is over and I come down from my teaching high, I inevitably lose faith in
the task, as I'm sure my students do. I envision the lot of us driving home,
solitary scholars in our cars, growing sadder by the mile. . .
I wonder, sometimes, at the conclusion of
a course, when I fail nine out of 15 students, whether the college will send me
a note either (1) informing me of a serious bottleneck in the march toward
commencement and demanding that I pass more students, or (2) commending me on
my fiscal ingenuity - my high failure rate forces students to pay for classes
two or three times over.
What actually happens is that nothing
happens. I feel no pressure from the colleges in either direction. My
department chairpersons, on those rare occasions when I see them, are friendly,
even warm. They don't mention all those students who have failed my courses,
and I don't bring them up. There seems, as is often the case in colleges, to be
a huge gulf between academia and reality. No one is thinking about the larger
implications, let alone the morality, of admitting so many students to classes
they cannot possibly pass. The colleges and the students and I are bobbing up
and down in a great wave of societal forces - social optimism on a large scale,
the sense of college as both a universal right and a need, financial necessity
on the part of the colleges and the students alike, the desire to maintain high
academic standards while admitting marginal students - that have coalesced into
a mini-tsunami of difficulty. No one has drawn up the flowchart and seen that,
although more-widespread college admission is a bonanza for the colleges and
nice for the students and makes the entire United States of America feel rather
pleased with itself, there is one point of irreconcilable conflict in the
system, and that is the moment when the adjunct instructor, who by the nature
of his job teaches the worst students, must ink the F on that first
writing assignment.
Recently, I gave a student a failing grade
on her research paper. She was a woman in her 40s; I will call her Ms. L. She
looked at her paper, and my comments, and the grade. "I can't believe
it," she said softly. "I was so proud of myself for having written a
college paper."
From the beginning of our association
vis-à-vis the research paper, I knew that there would be trouble with Ms. L.
When I give out this assignment, I usually
bring the class to the college library for a lesson on Internet-based research.
I ask them about their computer skills, and some say they have none, fessing up
to being computer illiterate and saying, timorously, how hopeless they are at
that sort of thing. It often turns out, though, that many of them have at least
sent and received e-mail and Googled their neighbors, and it doesn't take me
long to demonstrate how to search for journal articles in such databases as
Academic Search Premier and JSTOR.
Ms. L., it was clear to me, had never been
on the Internet. She quite possibly had never sat in front of a computer. The
concept of a link was news to her. She didn't know that if something was blue
and underlined, you could click on it. She was preserved in the amber of 1990,
struggling with the basic syntax of the World Wide Web. She peered intently at
the screen and chewed a fingernail. She was flummoxed.
I had responsibilities to the rest of my
students, so only when the class ended could I sit with her and work on some of
the basics. It didn't go well. She wasn't absorbing anything. The wall had gone
up, the wall known to every teacher at every level: the wall of defeat and
hopelessness and humiliation, the wall that is an impenetrable barrier to
learning. She wasn't hearing a word I said.
"You might want to get some extra
help," I told her. "You can schedule a private session with the
librarian."
"I'll get it," she said. "I
just need a little time."
"You have some computer-skills
deficits," I told her. "You should address them as soon as you
can." I don't have cause to use much educational jargon, but deficits
has often come in handy. It conveys the seriousness of the situation, the
student's jaw-dropping lack of ability, without being judgmental. I tried to
jostle her along. "You should schedule that appointment right now. The
librarian is at the desk. "
"I realize I have a lot of work to
do," she said.
Our dialogue had turned oblique, as though
we now inhabited a Pinter play. . . .
At our next meeting after class in the
library, Ms. L. asked me whether she could do her paper on abortion. What
exactly, I asked, was the historical controversy? Well, she replied, whether it
should be allowed. She was stuck, I realized, in the well-worn groove of
assignments she had done in high school. I told her that I thought the abortion
question was more of an ethical dilemma than a historical controversy.
"I'll have to figure it all
out," she said.
She switched her topic a half-dozen times;
perhaps it would be fairer to say that she never really came up with one. I
wondered whether I should just give her one, then decided against it. Devising
a topic was part of the assignment.
"What about gun control?" she
asked.
I sighed. You could write, I told her,
about a particular piece of firearms-related legislation. Historians might disagree,
I said, about certain aspects of the bill's drafting. Remember, though, the
paper must be grounded in history. It could not be a discussion of the pros and
cons of gun control.
"All right," she said softly.
Needless to say, the paper she turned in
was a discussion of the pros and cons of gun control. At least, I think that
was the subject. There was no real thesis. The paper often lapsed into
incoherence. Sentences broke off in the middle of a line and resumed on the
next one, with the first word inappropriately capitalized. There was some
wavering between single- and double-spacing. She did quote articles, but cited
only databases - where were the journals themselves? The paper was also too
short: a bad job, and such small portions.
"I can't believe it," she said
when she received her F. "I was so proud of myself for having
written a college paper."
She most certainly hadn't written a
college paper, and she was a long way from doing so. Yet there she was in
college, paying lots of tuition for the privilege of pursuing a degree, which
she very likely needed to advance at work. Her deficits don't make her a bad
person or even unintelligent or unusual. Many people cannot write a research
paper, and few have to do so in their workaday life. But let's be frank: she
wasn't working at anything resembling a college level.
I gave Ms. L. the F and slept
poorly that night. Some of the failing grades I issue gnaw at me more than
others. In my ears rang her plaintive words, so emblematic of the tough spot in
which we both now found ourselves. Ms. L. had done everything that American
culture asked of her. She had gone back to school to better herself, and she
expected to be rewarded for it, not slapped down. She had failed not, as some
students do, by being absent too often or by blowing off assignments. She
simply was not qualified for college. What exactly, I wondered, was I
grading? I thought briefly of passing Ms. L., of slipping her the old
gentlewoman's C-minus. But I couldn't do it. It wouldn't be fair to the other
students. By passing Ms. L., I would be eroding the standards of the school for
which I worked. Besides, I nurse a healthy ration of paranoia. What if she were
a plant from The New York Times doing a story on the declining standards
of the nation's colleges? In my mind's eye, the front page of a newspaper spun
madly, as in old movies, coming to rest to reveal a damning headline:
THIS IS A C?
Illiterate Mess Garners ‘Average' Grade
Adjunct Says Student ‘Needed' to Pass, ‘Tried Hard'
No, I would adhere to academic standards,
and keep myself off the front page.
We think of college professors as being
profoundly indifferent to the grades they hand out. My own professors were
fairly haughty and aloof, showing little concern for the petty worries, grades
in particular, of their students. There was an enormous distance between
students and professors. The full-time, tenured professors at the colleges
where I teach may likewise feel comfortably separated from those whom they
instruct. Their students, the ones who attend class during daylight hours, tend
to be younger than mine. Many of them are in school on their parents' dime.
Professors can fail these young people with emotional impunity because many
such failures are the students' own fault: too much time spent texting, too
little time with the textbooks.
But my students and I are of a piece. I
could not be aloof, even if I wanted to be. Our presence together in these
evening classes is evidence that we all have screwed up. I'm working a second
job; they're trying desperately to get to a place where they don't have to. All
any of us wants is a free evening. Many of my students are in the vicinity of
my own age. Whatever our chronological ages, we are all adults, by which I mean
thoroughly saddled with children and mortgages and sputtering careers. We all
show up for class exhausted from working our full-time jobs. We carry knapsacks
and briefcases overspilling with the contents of our hectic lives. We smell of
the food we have eaten that day, and of the food we carry with us for the
evening. We reek of coffee and tuna oil. The rooms in which we study have been
used all day, and are filthy. Candy wrappers litter the aisles. We pile our
trash daintily atop filled garbage cans.
During breaks, my students scatter to
various corners and niches of the building, whip out their cell phones, and try
to maintain a home life. Burdened with their own assignments, they gamely try
to stay on top of their children's. Which problems do you have to do? …
That's not too many. Finish that and then do the spelling … No, you can't watch
Grey's Anatomy.
Adult education, nontraditional education,
education for returning students - whatever you want to call it - is a
substantial profit center for many colleges. Like factory owners, school
administrators are delighted with this idea of mounting a second shift of
learning in their classrooms, in the evenings, when the full-time students are
busy with such regular extracurricular pursuits of higher education as reading
Facebook and playing beer pong. If colleges could find a way to mount a third,
graveyard shift, as Henry Ford's Willow Run did at the height of the Second
World War, I believe that they would.
There is a sense that the American
workforce needs to be more professional at every level. Many jobs that never
before required college now call for at least some post-secondary course work.
School custodians, those who run the boilers and spread synthetic sawdust on
vomit, may not need college - but the people who supervise them, who decide
which brand of synthetic sawdust to procure, probably do. There is a sense that
our bank tellers should be college educated, and so should our medical-billing
techs, and our child-welfare officers, and our sheriffs and federal marshals. We
want the police officer who stops the car with the broken taillight to have a
nodding acquaintance with great literature. And when all is said and done, my
personal economic interest in booming college enrollments aside, I don't think
that's such a boneheaded idea. Reading literature at the college level is a
route to spacious thinking, to an acquaintance with certain profound ideas,
that is of value to anyone. Will having read Invisible Man make a police
officer less likely to indulge in racial profiling? Will a familiarity with
Steinbeck make him more sympathetic to the plight of the poor, so that he might
understand the lives of those who simply cannot get their taillights
fixed? Will it benefit the correctional officer to have read The
Autobiography of Malcolm X? The health-care worker Arrowsmith?
Should the child-welfare officer read Plath's "Daddy"? Such
one-to-one correspondences probably don't hold. But although I may be biased,
being an English instructor and all, I can't shake the sense that reading
literature is informative and broadening and ultimately good for you. If I
should fall ill, I suppose I would rather the hospital billing staff had read The
Pickwick Papers, particularly the parts set in debtors' prison. . .
Sending everyone under the sun to college
is a noble initiative. Academia is all for it, naturally. Industry is all for
it; some companies even help with tuition costs. Government is all for it; the
truly needy have lots of opportunities for financial aid. The media applauds it
- try to imagine someone speaking out against the idea. To oppose such a scheme
of inclusion would be positively churlish. But one piece of the puzzle hasn't
been figured into the equation, to use the sort of phrase I encounter in the
papers submitted by my English 101 students. The zeitgeist of academic
possibility is a great inverted pyramid, and its rather sharp point is poking,
uncomfortably, a spot just about midway between my shoulder blades.
For I, who teach these low-level,
must-pass, no-multiple-choice-test classes, am the one who ultimately delivers
the news to those unfit for college: that they lack the most-basic skills and
have no sense of the volume of work required; that they are in some cases
barely literate; that they are so bereft of schemata, so dispossessed of
contexts in which to place newly acquired knowledge, that every bit of
information simply raises more questions. They are not ready for high school,
some of them, much less for college.
I am the man who has to lower the hammer.
We may look mild-mannered, we adjunct
instructors, but we are academic button men. I roam the halls of academe like a
modern Coriolanus bearing sword and grade book, "a thing of blood, whose
every motion / Was timed with dying cries."
I knew that Ms. L.'s paper would fail. I
knew it that first night in the library. But I couldn't tell her that she
wasn't ready for an introductory English class. I wouldn't be saving her from
the humiliation of defeat by a class she simply couldn't handle. I'd be a
sexist, ageist, intellectual snob.
In her own mind, Ms. L. had triumphed over
adversity. In her own mind, she was a feel-good segment on Oprah. Everyone
wants to triumph. But not everyone can - in fact, most can't. If they could, it
wouldn't be any kind of a triumph at all. Never would I want to cheapen the
accomplishments of those who really have conquered college, who were able to
get past their deficits and earn a diploma, maybe even climbing onto the
college honor roll. That is truly something.
One of the things I try to do on the first
night of English 102 is relate the literary techniques we will study to novels
that the students have already read. I try to find books familiar to everyone.
This has so far proven impossible. My students don't read much, as a rule, and
though I think of them monolithically, they don't really share a culture. To
Kill a Mockingbird? Nope. (And I thought everyone had read that!) Animal
Farm? No. If they have read it, they don't remember it. The Outsiders?
The Chocolate War? No and no. Charlotte's Web? You'd think so,
but no. So then I expand the exercise to general works of narrative art,
meaning movies, but that doesn't work much better. Oddly, there are no movies
that they all have seen - well, except for one. They've all seen The Wizard
of Oz. Some have caught it multiple times. So we work with the old warhorse
of a quest narrative. The farmhands' early conversation illustrates foreshadowing.
The witch melts at the climax. Theme? Hands fly up. Everybody
knows that one - perhaps all too well. Dorothy learns that she can do anything
she puts her mind to and that all the tools she needs to succeed are already
within her. I skip the denouement: the intellectually ambitious
scarecrow proudly mangles the Pythagorean theorem and is awarded a questionable
diploma in a dreamland far removed from reality. That's art holding up a mirror
all too closely to our own poignant scholarly endeavors.
To read the entire article, go to www.theatlantic.com/doc/200806/college.
* * * * *
2.
In the News: Lean
is Invading Health Care by James P.
Womack
How do we judge the progress
of the Lean Movement? One critical indicator is our success in extending lean thinking
to new industries and activities. In recent years, I have been greatly
encouraged that lean thinking is moving far beyond its origins in manufacturing
to distribution, retailing, maintenance and overhaul, consumer services,
construction, and – perhaps most striking – healthcare. Indeed, the
latter may be the most energetic area of lean practice today.
However, I have been
concerned about our prospects for changing the thinking of investors, and
specifically the giant private-equity investment firms that now control large
parts of the economy. While we have gained a strong foothold in financial
services, this has been at the operating level. Most efforts to date have
focused on how value streams within financial firms can be made lean -- for
example, those for processing loans or making credit checks. This is important
work but it is on a different level from how financial firms think about
investments and specifically how they might instigate lean transformations in
the firms they control in many industries.
I was therefore delighted
recently when I was contacted by one of the largest private-equity firms, an
organization with dozens of firms in its investment portfolio garnering perhaps
100 billion dollars in total sales. This type of firm pools private investment
funds to buy companies, in hopes of quick "turnarounds" with re-sale
of these firms at much higher prices.
The partner contacting me
noted that conditions in this industry have changed with the credit crisis and
weak equities markets. Instead of selling firms after two or three years it may
be necessary to hold onto them for a long time, even a decade, before they can
be sold to advantage. His question was a simple one: "Given that we may
now need to hold firms for many years, how can we take the long view. Indeed,
how can we turn firms into the ‘Toyota' of their industries in order to
maximize their price when they are sold?"
I was delighted to engage in
this conversation. But to avoid any misunderstanding I needed to start by
comparing a traditional private equity "turnaround" with a "lean
transformation". In the former, the objective to this point has been to go
quickly to produce a dramatic bottom-line result. This has often meant:
• "Rolling up" two
or more companies in the same industry to reduce competition and increase
prices to consumers.
• Negotiating lower wages
and benefits.
• Cutting spending on
long-term development projects not critical to the firm's strategic plan.
• Reducing headcounts in
activities judged non-essential.
• Restructuring the balance
sheet to add bank debt, often creating instant dividends for the private equity
firm but high levels of long-term debt for the firm once it is sold.
• Re-negotiating prices with
suppliers, on threat of loss of business.
These actions quickly shift
wealth from customers, employees, suppliers, and former owners to the new
owners. This may do more good than harm, because otherwise the firm in question
may completely fail. But it is often unclear that any additional value has been
created in the sense of better satisfying customer needs with a given amount of
human effort and capital investment. And, from society's standpoint, the only
way to increase living standards is to change the ratio of human effort and
capital going into firms to the amount of value coming out. Otherwise the
outcome is basically zero- sum, with some winners and some losers.
By contrast, the objective
of a lean transformation is to analyze the core value creating processes of
organizations in light of customer needs (which may have changed), then figure
out how to create more value with the same resources so the organizations can
grow and society can prosper. It's the difference between shifting wealth from
one party to another and creating more value, ideally value that can be shared
with customers, employees, suppliers and owners. (Note that I never use the
term "adding value" because this is an accounting convention for the
difference between the input costs of a firm and its output prices. Often I
find that only cost is added by the firm as inputs are converted to outputs,
not value from the customer's standpoint.)
I was relieved that after a
frank discussion of the differences between traditional and "lean"
private equity, the firm in question was still interested in pursuing lean.
Indeed, this firm has now launched a wide range of experiments to
"lean" the processes of its portfolio firms, and other private equity
firms are now following its lead. It is far too soon to know how much progress
will be made along this new path. But I'm heartened that an industry I feared I
would never hear from is now actually listening.
As I always tell audiences,
managers (and owners) will try anything that is quick and easy even if it
doesn't work (e.g. many of the traditional methods of private equity in the
current environment) before they try anything long and hard that does work
(e.g. intense process analysis linked to customer needs to create more value
from the same resources.) So perhaps the massive private-equity industry, by
virtue of the recent shifts in the global economy, is now ready to tackle long,
hard things which do work.
James P. Womack
Founder and Chairman
Lean Enterprise Institute
P.S. As I travel to visit
companies and make presentations on lean thinking, I am bemused by the
perception that LEI is a private consulting firm. While our faculty members and
authors make most of their living in independent consulting businesses, LEI
itself is a non-profit organization with no owners and no consulting contracts.
We are chartered to teach courses, hold management seminars, write and publish
books and workbooks, and organize public and private conferences. We use the
surplus revenues from these activities to conduct research projects and to
support other lean initiatives such as the Lean Education Academic Network (www.teachinglean.org) and the Lean Global
Network (www.leanglobal.org). Our activities are a continuation
of the educational work I did for many years at MIT, directly across the street
from our LEI office in Cambridge, MA.
* * * * *
3.
International
Medicine: The Private Cost of Public Queues by Nadeem Esmail
This past October, The Fraser Institute released its
seventeenth annual measurement of waiting times for medically necessary
treatments in Canada (Esmail and Walker with Bank, 2007). This most recent
measurement shows that the national median waiting time from appointment with a
specialist to treatment rose slightly from 9.0 weeks in 2006 to 9.1 weeks in
2007. Put simply, the impact of waiting times from specialist to treatment on
Canadians in 2007 was similar to that in 2006.
But the measurement of waiting times, or the
examination of the absolute delay Canadians must endure in order to receive
medically necessary care, is only one way of looking at the burden of waiting
for health care. We can also calculate the privately borne cost of waiting: the
value of time that is lost while waiting for treatment. While the absolute
delay Canadians endured in 2007 was similar to that in 2006, it is entirely
possible that the value Canadians place on time has changed over the past year
in such a way that a marked change in the impact of wait times for treatment
has taken place.
The privately borne cost of
waiting for care
One way of estimating the privately borne cost of care
in Canada was originally developed by Steven Globerman and Lorna Hoye
(1990).They calculated the cost of waiting by estimating the amount of time
that could not be used productively by a patient while he was waiting for
treatment.
Globerman and Hoye's methodology is relatively simple.
First, the number of patients who are waiting for treatment is multiplied by
the wait times for those treatments in order to derive an estimate of the total
number of weeks all patients will spend waiting for care. This value is then multiplied by a measure
of the proportion of time spent waiting for treatment that is rendered
unproductive by the physical and emotional impact of an untreated medical
condition. The monetary value of this lost productive time is then
estimated. In 2007, an estimated
827,429 Canadians were waiting for care after an appointment with a specialist
(table 1).
These Canadians waited, on average, 9.1 weeks for
treatment though those wait times varied significantly when broken down by province and
medical specialty (table 2). Multiplying the number of Canadians waiting in
each of the 12 medical specialties in each of the 10 provinces by the weighted
median wait time for that medical specialty in that province gives a rough
estimate of the total amount of time that Canadians waited for treatment in
2007: about 9.99 million weeks this year. This estimate is slightly greater
than the estimate of 9.86 million weeks for 2006 (Esmail, 2006).
Globerman and Hoye's original estimate for the cost of
waiting, which came from responses to a survey of physicians, used
specialty-specific measures of the proportion of patients who were
"experiencing significant difficulty in carrying on their work or daily
duties as a result of their medical condition." The proportions they
estimated ranged from 14% of patients in gynaecology to 88% in cardiovascular
surgery, and averaged 41% overall (Globerman and Hoye, 1990; Esmail and Walker
with Bank, 2007). However, the estimates of lost productivity measured by
Globerman and Hoye cannot necessarily be applied today because of advances in
the medical system's ability to deal with pain and discomfort through
pharmaceuticals. These advances may allow many Canadians who are suffering
significant difficulties to function at a higher level today than they would
have in 1990, or even to maintain their normal activity levels. For this
reason, this author's estimation of the cost of waiting in 2007 uses a
Statistics Canada finding that 11.0% of people were adversely affected by their
wait for non-emergency surgery in 2005 (Statistics Canada, 2006). This
percentage is below even the lowest specialty specific measure estimated by
Globerman and Hoye (1990).
An assumption that 11.0% of people waiting for
treatment in 2007 experienced significant difficulties in their daily lives as
a result of their medical condition, and thus lost productivity while waiting
for treatment, results in an estimate that nearly 1.1 million weeks were
"lost" while patients waited for treatment. However, because this
estimate is based on the assumption that all individuals face the same wait time
for treatment in each specialty/province combination, it is mathematically
equivalent to assuming that 11.0% of the productivity of all Canadians waiting
for care was lost to a combination of mental anguish and the pain and suffering
that accompany any wait for treatment. Multiplying this lost time by an
estimate of the average weekly wage of Canadians in 2007 (given in table 3),
which provides an estimate of the value of lost time to each individual,6 gives
an estimate of the cost of the productive time that was lost due to individuals
waiting for medically necessary treatment in 2007 (table 4).
The estimated cost of waiting for care in Canada for
patients who were in the queue in 2007, according to calculations based on the methodology
produced by Globerman and Hoye (1990), was slightly more than $793 million.
That cost works out to an average of about $959 for each of the estimated
827,429 Canadians waiting for treatment in 2007. Alternatively, that cost works
out to roughly $8,716 for each individual among the 11.0% percent of patients
in the queue who were suffering considerable hardships while waiting for care.
Of course, this figure is a conservative estimate of
the private cost of waiting for care in Canada. This estimate assumes that only
those hours during the average work week should be counted as lost. It places
no intrinsic value on the time individuals spend waiting in a reduced capacity
outside of the working week. Valuing all hours of the week, including evenings and
weekends but excluding eight hours of sleep per night, at the average hourly
wage (given in table 3) would increase the estimated cost of waiting to more
than $2.42 billion, or about $2,919 per person. . .
To read the entire report, go to www.fraserinstitute.org/commerce.web/product_files/Dec07FFFull.pdf.
Canadian Medicare does not
give timely access to healthcare, it only gives access to a waiting list.
--Canadian Supreme Court Decision 2005 SCC 35, [2005] 1 S.C.R.
791
http://scc.lexum.umontreal.ca/en/2005/2005scc35/2005scc35.html
* * * * *
4.
Medicare:
Medicare spending will consume nearly the entire federal budget by 2082.
SOCIAL SECURITY
AND MEDICARE PROJECTIONS: 2008
- Until recently, the combined effect of Social
Security and Medicare on the rest of the federal government was relatively
small. The combined deficits of both programs now require about 8
percent of general income tax revenues. As the baby boomers begin to
retire, however, that number will soar, and, as a result, it will be
increasingly difficult for the federal government to continue spending on
other activities, says Pamela Villarreal, a policy analyst with the
National Center for Policy Analysis.
According to the Congressional Budget Office (CBO), if
Medicare spending continues to grow at the historical growth rate of total health
care spending:
- Social Security, Medicare and Medicaid (the
health care program for the poor) will consume nearly the entire federal
budget by 2050.
- By 2082 Medicare spending alone will consume
nearly the entire federal budget.
The CBO also found that if federal income tax rates
are adjusted to allow the government to continue its current level of activity
and balance the budget:
- The lowest marginal tax bracket of 10 percent
would have to rise to 26 percent.
- The 25 percent marginal tax bracket would increase
to 66 percent.
- The current highest marginal tax bracket (35
percent) would have to rise to 92 percent!
- Additionally, the top corporate income tax rate
of 35 percent would have to increase to 92 percent.
Source: Pamela Villarreal, "Social Security and
Medicare Projections: 2008," National Center for Policy Analysis, Brief
Analysis No. 616, April 30, 2008.
To read the entire article, go to www.ncpa.org/sub/dpd/index.php?Article_ID=16451.
For more on Social Security Issues: www.ncpa.org/sub/dpd/index.php?Article_Category=39
Government
is not the solution to our problems, government is the problem.
- Ronald Reagan
* * * * *
5.
Medical Gluttony:
Sacramento Hospitals Bulking Up
UC
Davis, Sutter, Catholic Healthcare West and Kaiser to add 3.5 million square
feet.
By Dorsey Griffith - dgriffith@sacbee.com Sunday, May 4, 2008
The housing industry is in a free fall. Businesses are
struggling. And city and county governments face mounting budget deficits.
But try navigating the construction maze created by Sutter
Health's projects in Sacramento's midtown, or look for parking at Kaiser's
South Sacramento Medical Center, where backhoes and bulldozers have ripped into
what seems like every square inch of ground.
A massive construction boom by the area's four big
hospital groups has become a bright spot in the region's otherwise gloomy
economic panorama.
The expansion represents the largest ever in the
Sacramento area for UC Davis Health System, Sutter Health, Catholic Healthcare
West and Kaiser Permanente. Together, the more than 3.5 million square feet of
construction could fill eight Arco Arenas.
The regional price tag: $2.6 billion, more than two
times the city of Sacramento's annual budget, or enough to buy about 8,650 new
homes at $300,000 apiece.
The makeover is expected to add as many as 2,000
health care jobs to the local economy by 2013, and already has generated
hundreds of local construction jobs. . .
The growth of the health care industry is nearly
unique in Sacramento's economic picture, said Ryan Sharp, director of the
Sacramento Regional Research Institute.
Other than state government, health care was the only
economic sector that grew in the six-county region between February 2007 and
February 2008.
"Health care has been a solid performer for our
economy for a long time," Sharp said. "As others have gone up and
down, it has been a stable provider of job growth for the region. It will help
minimize the downturn."
As brick and mortar are put down, however, questions
linger about the need for such ambitious expansion.
Bucking the trend
When it comes to new hospital beds, Sacramento's plan
appears to buck the trend across the country, where per-capita bed rates have
dropped steadily nationwide over the past 50 years to about three per 1,000 people.
. .
Consider what's on Sacramento's horizon:
• More than 800 new hospital beds, including at least
90 new emergency room beds and about 80 intensive-care beds for infants and
children.
• A 40-bed acute rehabilitation center for the care of
patients recovering from strokes, orthopedic surgery, brain and spinal cord
injuries and other trauma.
• A state-of-the-art communications hub for
telemedicine, which will extend medical attention to rural reaches of Northern
California.
• A stem cell research center.
• More than a million square feet of new clinics,
medical offices and outpatient surgery suites.
• More than 2,000 new hospital parking spaces.
Other perks in the pipeline for patients: lots of
private, family-friendly rooms, convenient walkways connecting clinical units,
and modern floors painted in soothing colors, with plenty of art.
What's driving the boom?
Looming state earthquake safety requirements for
hospitals are a major factor behind the expansion, but do not account for all
of it.
Hospitals – many of them dated and ill-equipped for
new medical technology – had long put off major renovation and expansion,
explained Robert David, chief deputy director at the Office of Statewide Health
Planning and Development.
"Back in the early 1990s … managed care companies
negotiated contracts that were very unfavorable to hospitals, and they all lost
gobs of money," he said. "(Hospitals) had no money for capital
improvements."
That changed, he said, when hospitals merged into
systems, gained financial leverage and negotiated better rates. . .
A shadow of doubt
Whether the massive expenditures will prove prudent
down the road, however, is a matter of opinion.
Maribeth Shannon, who tracks market trends for the California
Healthcare Foundation, said that while Sacramento has historically operated its
hospitals very efficiently, huge cuts in reimbursement rates from federal and
state health insurance programs could make it hard to justify such an
investment.
"It's just amazing all this can get funded given
the outlook for Medicare and Medi-Cal cutbacks," Shannon said. "They
have strong stomachs." . . .
But there's no guarantee the billions spent on new and
spruced-up buildings will yield better outcomes or lower bills for patients
with heart attacks, broken legs or kidney failure. Research shows more services
lead to higher utilization and costs – but not necessarily better results for
patients.
"What are we getting for all this money in terms
of the quality of care and its cost?" asked Chris Ohman, CEO of the
California Association of Health Plans, which represents the insurance
industry. "The big deal is, we don't really know."
www.sacbee.com/health/v-print/story/911398.html
* * * * *
6.
Government Myths:
Government can control disasters.
How Government Makes Disasters More Disastrous, By Thomas A. Bowden
In a speech from New Orleans
last week, Republican presidential candidate John McCain lashed out at the Bush
administration for its response to Hurricane Katrina. McCain's remarks, which
appeared calculated to make disaster relief a key campaign issue, revived harsh
memories of the savage storm that inundated the Mississippi Delta in late August
2005, leaving more than 1,800 people dead and causing widespread property
damage.
Although the floodwaters
long ago receded, government officials are still counting the disaster's costs.
Earlier this year, the U.S. Army Corps of Engineers disclosed that 489,000
claimants are seeking damages caused by poorly designed levees. Of those
claimants, 247 want more than $1 billion each, including one whopper for $3
quadrillion (a stack of a quadrillion dollar coins would reach beyond Saturn).
The tax dollars spent
resolving those claims will augment the tens of billions already paid to
restore and repopulate New Orleans, a below-sea-level bowl situated
precariously amidst a lake, a major river, and a gulf, in a known path for
hurricanes.
Disasters can sometimes shock
a nation into questioning entrenched practices. But Hurricane Katrina, perhaps
the worst natural disaster ever to befall America, has failed to spark serious
challenge to long-standing government policies that actively promote building
and living in disaster-prone areas.
The Katrina tragedy should
have called into question the so-called safety net composed of government
policies that actually encourage people to embrace risks they would otherwise
shun--to build in defiance of historically obvious dangers, secure in the
knowledge that innocent others will be forced to share the costs when the worst
happens.
Without blaming the victims
for having followed their own government's lead, it is time to question whether
those policies should continue.
The first strands of today's
safety net were spun in the nineteenth century, as the Army Corps of Engineers
shouldered the burden of constructing and maintaining levees and other flood
controls along the Mississippi River. From then to now, Congress and the states
have responded to each new flood by installing newer, higher, and stronger
barriers at public expense, as if the preservation of a city like New Orleans
in its historical location were a self-evident necessity.
Throughout the twentieth
century, new strands were woven into the safety net, first in the form of loans
to disaster victims, then by direct grants, infrastructure repairs, loan
guarantees, job training, subsidized investments, health care, debris removal,
and a host of similar rehabilitative measures.
In 1968, the National Flood
Insurance Program began supplying subsidized coverage for structures and their
contents in flood-prone areas. Similar state-subsidized insurance programs
arose for hurricanes in Florida and earthquakes in California. In 1978, the
Federal Emergency Management Agency was created to coordinate the increasingly
complex job of government disaster response.
At each juncture, more aid
was funneled to disaster victims without serious challenge to the wisdom of
encouraging people to occupy vulnerable locations.
In response to Mississippi
floods, Florida hurricanes, and California earthquakes, the number of major
disaster declarations almost doubled from the 1980s to the 1990s, from an
annual average of 24 up to 46. At century's end, Congress was paying an average
of $3.7 billion a year in supplemental disaster aid, with state taxpayers
contributing many millions more. As of August 2007, Katrina relief alone had
cost federal taxpayers $114 billion.
By gradual steps, this
disaster safety net became part of the legal landscape, taken for granted by
private investors and owners deciding to undertake new projects or rebuild
storm-damaged areas. Relief programs--by minimizing, disguising, and shifting
the real risks of defying natural hazards--became an active force distorting
private decision-making and inviting even worse future tragedies.
Thus if a pre-Katrina
Mississippian asked himself, "Should I build my house 10 feet above sea
level, a quarter-mile from the Gulf Coast?" the answer came back:
"Sure, why not? The government will look after me if disaster
strikes."
This entitlement mentality
ensured that each new tragedy would generate fresh demands to expand the safety
net. In Katrina's aftermath, those demands centered on State Farm, which dared
to deny certain claims under homeowners policies that covered wind damage but
expressly excluded floods. Mississippi's attorney general immediately sued to
void flood exclusion clauses as "unconscionable" and "contrary
to public policy" and even launched a criminal investigation of State
Farm's claims adjusting practices.
Last year, a jury inflamed
by adverse public opinion awarded $1 million in punitive damages against State
Farm for having stood on its contract rights in a dispute involving a single
house. That case was recently reversed on appeal, but the victory is cold
comfort for State Farm, which in the meantime elected prudently to calm the
litigation storm by paying tens of millions of dollars to settle claims for
unproven wind damage. Voila! The safety net had a brand new strand, woven at
the insurance company's expense.
Disgusted, State Farm
announced last year that it would cease writing new homeowners policies in
Mississippi.
As more private insurers
withdraw from high-hazard areas--or raise their rates to reflect the staggering
legal and public relations costs of offering disaster insurance--a predictable
lament arises: the free market has failed, and government must fill the vacuum
so that the statist safety net remains strong. Thus it surprises no one to hear
Florida Gov. Charlie Crist challenging this year's presidential candidates to
support creation of a federal catastrophic fund that would keep insurance
premiums artificially low in disaster-prone areas across the country.
But the solution is not more
of the market distortions and perverse incentives that have lured so many
people into harm's way. The solution is to replace the prevailing entitlement
mentality with a free market in disaster prevention, insurance, and recovery.
In a free market--without
tax-paid levees, government disaster relief, or subsidized insurance--anyone
who contemplates building or buying property in a high-hazard area will need to
face hard facts about the local history of natural disasters, the efficacy and cost
of preventive measures, and the availability of insurance. . .
With their own lives and
wealth at stake, people will have every incentive to evaluate risks
objectively. And if hardy souls still choose to occupy and fortify New Orleans,
or build on an earthquake fault, or live in a tornado alley, the risk and
reward will be theirs alone. No longer will government make disasters more
disastrous by pretending that citizens have a right to defy the forces of
nature at others' expense.
Thomas A. Bowden is an analyst at
the Ayn Rand Institute, focusing on legal issues. Mr. Bowden is a former
attorney and law school instructor who practiced for twenty years in Baltimore,
Maryland. The Ayn Rand Institute promotes Objectivism, the philosophy of Ayn
Rand--author of "Atlas Shrugged" and "The Fountainhead."
Contact the writer at media@aynrand.org.
To read more, go to www.aynrand.org/site/News2?page=NewsArticle&id=17647.
Government health care subsidies also create health
care disasters.
* * * * *
7.
Overheard in the
Medical Staff Lounge: Physicians need help in reducing health care costs.
Dr. Rosen: I
think we have a crisis in our profession.
Dr. Ruth: How
so?
Dr. Rosen: The
government, Medicare, Medicaid, health insurers in general and HMOs all expect
us to control health care costs. They expect us to be the cops on patients we
serve.
Dr. Sam: I
just tell my patients that the fancy test they are wanting is not reasonable.
Dr. Ruth: If
that works, that must keep your profile very low and your HMO bonuses very
high.
Dr. Sam: Well,
my bonuses at the end of each quarter are nearly one third of my income.
Dr. Rosen: Isn't
that manipulation galling to you?
Dr. Sam: Well,
no. I'm done fighting the system. I will comply with whatever they recommend
and collect my maximum compliance rewards.
Dr. Rosen:
Rewards? Isn't that subterfuge?
Dr. Ruth: I
have the same problem even though I basically do what Sam does. I have family
responsibilities and no interest in being a crusader or a hero. I want to be
the best doc that I can be while working in the system foisted upon us by the
powers that be.
Dr. Rosen: My,
aren't we compliant? But won't this sort of compliance eventually bury us all?
Dr. Ruth: By
that time, my kids will be married and I will settle for a life of being a
grandma since I've missed much of the rewards of being a mother.
Dr. Rosen: I admire your
honesty. Don't you think there are a lot of doctors in that situation, probably
more women than men?
Dr. Ruth: I'm
sorry to have come to this realization. When I graduated, I had a determination
that I would out work any male and I did for nearly a decade. But priorities
change. And mine are changing. I'm sorry that it was managed care that changed
mine. But my family will be richer for the experience.
Dr. Rosen:
Aren't you turning your profession into a job?
Dr. Ruth: Yes. To me medicine has become a job that pays
my mortgage and bills. Not much more.
Dr. Sam: Now
that our professional organizations have convinced doctors that bureaucratic
government medicine is the favored way to practice by 60 percent of us, I no
longer will give any resistance. I will also treat my profession as a job. When
the government wolves take over, the sheep and their Shepherds - our patients
and us - will have no options. The wolves are no more interested in the welfare
of the sheep than the government is interested in the welfare of our patients
or us. But I really think it was our fault and it's too late to correct. I'm
sorry to say, the wolves will eat the sheep. As Shepherds, with as high an IQ
as any profession, we can find another calling.
* * * * *
8.
Voices of
Medicine: A Review of Local and Regional Medical Journals and the Lay Press
Inside Medicine:
Mixed feelings after lecturing for Saudis, By
Dr. Michael Wilkes – Sacramento Bee, May 11, 2008
The large, modern, wood- paneled hospital auditorium was
filled to capacity as I finished my lecture at a new medical school in Riyadh,
Saudi Arabia.
I had decided to make a special effort not to ignore
the distant back-left corner of the auditorium. That is where the 100 or so
female doctors were sitting. They all appeared to be dressed alike, wearing the
jet-black abaya (robe), a head shawl, and a feesha, or facial covering. All
that could be seen were their dark-brown, inquisitive eyes. Just below the hem
of their robe was the only fashion statement visible – shoes of all sorts of
designs and colors from shimmering gold and silver to a pair of bright-red
sneakers.
Following the lecture, there was a flurry of questions
from the audience, but none from the women. During the short break that
followed I was surrounded by women who had insightful, informed medical
questions. Many of the women spoke English far better than their male
counterparts. It was an odd feeling, as not one person looked me in the eyes
when they asked a question. After 20 minutes there was only one woman left. Her
veil was unusually low on her face – almost to her neck – allowing me to see
her entire face. She wore dark mascara and tiny, gold earrings. Below her robe
I could barely make out the hem of her white slacks.
She shook my hand – the men all greeted me with a
handshake as they introduced themselves. But such contact between a man and a
woman is strictly forbidden in Saudi Arabia.
"I could see you are making a special effort to
speak to the women doctors," she said.
She introduced herself to me as Anna, and appeared to
be in her mid-30s. She asked permission to ask me a personal question, then
went on to explain that for nine years she had lived in California, where she
and her brother went to school, hoping she would learn the skills of an
American pediatrician and bring them back to Saudi Arabia to train future
doctors. . .
Anna had been back in Saudi Arabia for two years. As
we spoke, we strolled toward the back of the auditorium and sat down on two
folding chairs. She described how much she appreciated having a chance to train
in the United States. She reported learning so much – some of it medicine, but
some not. She made a number of friends, learned to drive a car and to have the
confidence enough to socialize as an equal with men, to wear western clothing,
and to learn about other religions and worldviews. She also learned to advocate
for herself.
But the blessing was mixed. She now finds her life in
Saudi Arabia intolerable – both personally and professionally. She cannot build
her career because men are threatened by her knowledge and her ideas for
change; they won't even meet with her. Socially, she can't go out at night or
socialize with men. Professionally, she must sit in the back of the auditorium,
she can train only females, and she must wear traditional attire.
Her question to me was simple: Should she stay and try
to change the system so other women would benefit? She described this route as
amounting to a lifetime of battles, a stagnant career and the likelihood that
she might never find a husband who would tolerate her free spirit and western
thoughts.
Or, she could return to the United States, where she
would be welcomed back to her old job and live her life as she wished, although
this would bring shame to her family. . .
Out of nowhere, an older woman came up to Anna and
whispered something in her ear. As the woman walked off she told me, "I
must go. It is not proper for me to be sitting here with you without another
woman present."
We were, after all, sitting in the back of a
500-person auditorium. I asked if she'd prefer to step outside the building,
where there were many women (the men were all congregating in the
air-conditioned lobby).
"No, this would not be proper for you to join the
women."
I asked if we could talk later, but she didn't reply.
Over the next week I looked for her in the auditorium.
Each time I spotted her she gave me a little wave. But
she never came up to me again.
As Americans reach out to train foreign doctors,
nurses and researchers, our intentions are great, and in most cases I hope that
their society ends up the better for our efforts.
But I wonder how often we create internal chaos for
those who come to learn science, but also learn about the American way of life
that can not be duplicated back home.
About the writer: Michael Wilkes, M.D., is a professor of
medicine at the University of California, Davis. Identifying characteristics of
patients mentioned in his column are changed to protect their confidentiality.
Reach him at drwilkes@sacbee.com.
To read the entire VOM, go to www.sacbee.com/107/v-print/story/926046.html.
* * * * *
9.
Book Review: From
our archives: False Hopes
FALSE HOPES - Why America's
Quest for Perfect Health Is a Recipe for Failure by Daniel Callahan, Simon
& Schuster, New York, 1998. 330 pp,$24, ISBN 0-684-81109-X
Daniel Callahan, cofounder
of the Hastings Center and the Director of its International Programs, takes on
the entire medical establishment--doctors, nurses, hospital administrators,
medical researchers, and pharmaceutical and medical technology companies--all
of whom he believes are united in a relentless pursuit of unlimited medical
progress, stopping at nothing short of the conquest of all disease and the
indefinite extension of life spans (see last month's review of Schwartz' Life Without Disease - The
Pursuit of Medical Utopia).
The Hastings Center is an avant-garde
institution where any idea can be explored (see "Duty to Die" in
the HHK column in this issue of the Journal). Callahan, as the president
of the Hastings Center from 1969 to 1996, must be taken seriously. In the
preface, he presents his political leanings, aligning himself with the Clintons
in their quest for healthcare reform. He bemoans the fact that no plan made it
through Congress--not one bill, not a single reform. Callahan is even more
appalled that at the next presidential election, both candidates all but
ignored the issue.
Initially, the reason he
takes this stance is not clear. However, he soon points out that the universal,
if poorly financed and often corrupt, healthcare systems in China, Southeast
Asia, and in much of Latin America, are turning to the marketplace and
accepting privatization as their new gospel. He finds it most unsettling that
the popular, well managed, equitable health care systems of Western Europe have
begun to unravel in the post WW II welfare state. These systems, beset with
rising costs, are high on the budgetary hit lists of political leaders who are
looking to the marketplace to reduce public benefits, thus securing their own
future.
Callahan realizes that if
everyone is having a problem, and all are looking for answers, there must be an
underlying basic issue. Almost all healthcare reform efforts assume that the
solution lies in better organization and financing. Callahan then observes that
no matter how much money is spent and no matter what the health gains may be,
they never seem to be enough. Conventional solutions do not address the real
problem. No matter how much progress, they always seem insufficient to meet the
"needs" of the day.
The most cherished and
celebrated aims, commitments, and values of modern medicine are beginning to
give us trouble. But challenging these ideas, Callahan reflects, is not new.
Rene Dubois in his 1954 book Mirage of Health questioned the then
imminently anticipated total conquest of disease and stated this would not
happen, not soon, not ever. In the 1970s, theologian Ivan Illich, British
physician John Powles, American physician Rick Carlson, and British professor
of social medicine, Thomas McKeown, each showed in a systematic way that there
is no clear correlation between population health and medical care. Carson
boldly predicted the diminishing impact of physicians and hospitals on health
by the year 2000.
Callahan emphasizes that
"A serious transformation will require taking money away from the
acute-care sector, including research into the cure of many lethal diseases,
and using it instead on prevention research and massive educational efforts
designed to change health-related behavior." Callahan asserts that
sustainable medicine will do the following: give priority to preventing and
treating diseases that afflict the many rather than finding cures for diseases
that effect the few, improve the quality of life for the elderly rather than
extend life indefinitely, and focus on primary care and public health measures
that benefit society as a whole rather than satisfying the health needs of
individuals.
Callahan as an ethicist
explores topics and issues on which to base future dialogue as well as change
the direction of the debate. But he doesn't give us the final answer. He does
point out that many Americans are bypassing traditional physicians and
hospitals and are going to alternative medicine practitioners whom they pay
from their own pockets. According to some estimates, these visits exceed those
to traditional practitioners. This demonstrates that patients will pay for what
they perceive as valuable.
However, Callahan's
prejudices outlined in the preface, may prevent an objective extension of the
excellent groundwork he has developed. He might also have mentioned that the
current debates in Britain and Europe include proposals for a significant
transfer of costs from the national health systems to the individual through
major co-payment plans, not only for office visits, but also for hospital stays
in some instances. That may not be politically correct, but it would be a giant
step toward what is economically correct for our patients.
Del Meyer, MD
This review is found at www.delmeyer.net/bkrv1098.htm.
To read more reviews, go to www.delmeyer.net/PhysicianPatientBookshelf.htm.
* * * * *
10. Hippocrates & His Kin: A New Way to Cut Health
Care Costs
Q. Is there a new code for ventilation assistance and
management? I have been using 94656 and 94657.
A. If you reported 94656 or 94657 since January 1,
2007, you should have been denied payment. These codes were deleted in CPT
2007. Please review your accounts receivable. Check with insurers on how
far back you can resubmit claims processed in error. These codes have been
replaced by the following four codes since January 1, 2007. . .
Since the code books are as large as textbooks required
in medical school, taking a full semester to learn, any physician should be
able to take off a semester every other year to study and digest the new codes.
When the physician pays his biller a hundred hours or two at $25 an hour, he
may find the reimbursement for the new codes is actually an administrative
maneuver to reduce his income.
The Medical Association, that represents 25 percent of
physicians, produce the CPT codes and makes them more money than all the dues
the doctors pay.
Nirvana: It looks like the answer to controlling
health care costs is a new Current Procedural Terminology (CPT) book every
year. Doctors won't get paid until it's too late to correct or collect.
Insurance carriers as
Consulting (Controlling) Physicians
I received a notice from BC-BS stating "available
claims suggest your patient has diabetes with no recent history of
lipid-lowering therapy. If your patient does not have diabetes, please
disregard this.
"If after evaluating the overall treatment goals
for your patient . . . please consider: Adding lipid-lowering therapy. Note
that lipid-lowering therapy should be accompanied by laboratory monitoring
(e.g. lipid panels, creatine kinase, liver function tests) and follow-up
visits.
"If necessary, please provide your patient a new
prescription."
The insurance company's meddling in the private
practice of medicine is very costly and does not improve the quality of
health care or patient well being. This patient is of advanced age (ninth
decade of life), and the lipids are only mildly abnormal and will not affect
lifespan even without treatment. Furthermore, treatment with statin has certain
risks and may cause myopathy and myoglobinuria, renal failure and death.
Avoiding death can increase health care costs by a thousand fold if renal
complication occurs. The monitoring guidelines mentioned will further increase
the cost of statin therapy by two to fourfold. The inconvenience and hazards of
more frequent visits to the office, laboratory and pharmacy would decrease the
quality of this patient's final years of life.
As is generally the case, medical treatment guidelines
and government and insurance companies interference, will increase health care
costs significantly - in the range of 10 to 1000 times normal. (1000 to 100,000
percent increase). It would be fair to project that if all the various
recommendations were followed, the $2 trillion annual health care costs could
easily be pushed to 4 trillion and quality would not be better.
It would be more cost effective if Congress rather
than doctors and hospitals were held accountable for their actions. At least
doctors have medical expertise to vary treatment based on clinical judgment,
which is totally lacking in congressional or insurance carrier meddling.
To read more HHK medical
vignettes, please go to www.healthcarecom.net/hhk2001.htm.
To read more HMC, go to www.delmeyer.net/hmc2002.htm.
* * * * *
11. Organizations Restoring Accountability in HealthCare,
Government and Society:
