Obama Care

ObamaCare is The Patient Protection and the Affordable Care Act, a bill signed into law to reform health care. Unfortunately, it doesn't address the fundamental issues.

Obama has decided that the solution is micromanaging health care (20,000 regulations so far and growing), like Franco tried with the Spanish food industry. Franco ended up with a nation known for having the worst food in the world, until Franco died. And now Spain is spoken of as possibly having the best food in the world, something that does not result from bureaucracies micromanaging entire sectors of an economy.

Not in the last 160 years

160 years ago, when it was discovered that fewer patients die when doctors wash their hands, efforts were begun to try to get doctors to do that. We're still trying. 160 years of trying to fix it in that way is enough time to understand that fixing it in that way is the wrong approach. It's the wrong paradigm in which to think.

Obama-Care: When something doesn't work do more of it

ObamaCare is imagining that something that hasn't worked in 160 years just needs for us to do a whole lot more of it.

It's too bad Obama comes from law and not business. Any experience with running a business could have helped him understand. Even show business. Even the most basic show business of all, street performing.

Regulating Cost and Safety

Once upon a time in New York City there were street performers. Sometimes you would stumble upon them in Greenwich Village late at night attracting a small crowd for a performance on the sidewalk. Sometimes a performer would appear on the grass in Central Park. But the best place of all to see them was weekend afternoons in Washington Square Park. People used to go there just for that.

Franco Already Tried Regulating an industry like that

The performers there were within sight and earshot of each other. They competed with each other attract each other's audiences. At the end of their shows they would pass a hat. If they were good performers, people were generous. If they were not, people were not. I saw some brilliant performers there, some I never will forget (including, one time, Phillip Petite, the guy who tight-rope walked from one World Trade Center tower to the other, doing a low wire act between two trees).

I had heard that in Boston, in the Faneuil Hall Marketplace area, they had street performers too. But in Boston the street performers were regulated. They had to audition. They had to get permits. It was said that there were no bad shows because the poor performers had been weeded out by a process set up to regulate them.

The next time I was in Boston I went to see them. They were the most tired, uninspired performers I ever have seen. Even kids just working out their acts for the first time in New York had more life in them. In Boston they dragged themselves through repetitions of acts they didn't even listen to themselves, and then were rude if you left before they passed the hat. In New York when the audience began leaving before the act was finished, the performers knew it was their own fault and that they had to improve their acts. In Boston, they didn't. They had been certified.

A performer in Boston accosted me when I turned to leave halfway through his act. He said that he had performed for me and now I should pay. He didn't even like his audience. He didn't feel he needed to give anything other than his time, and having given that he believed he was owed something, even when he had given nothing other than time, which in fact he had taken from his audience. He took their time without giving anything in return. He was an insult to street performers.

Like when the focus is on
External Objectives rather than Patient Outcomes

Think how long it has been since caregivers had  to worry about having  their pay depend on actually doing something for patients. Your caregivers can grope you and infect you and put lies in your record to make sure no one diagnoses the injuries they gave you, leaving you worse off than you were before you saw them, and still believe they deserve to be paid and deserve to have good reputations. They get certified by experts, not the community of patients.

Confidence born of ignorance

Sometimes pages of rules overseen by regulatory agencies populated by well meaning people kill inspiration, empathy and common sense. The people on the frontline have their focus shifted away from serving the recipients and toward serving regulators and rules. In medicine the recipients of services are prevented from knowing who the good performers are until its too late. And then they are prevented from warning other patients (covered in detail on this site on pages like this one and this one).

The performers do not need to compete to attract patients because patients cannot figure out who is good or bad or even who is affordable. Caregivers get paid even when all they do is mail in a poor excuse for performance, even when they lash out at their audience, even in ways that ruin the lives of their customers.

Somehow these caregivers believe, and lead everyone else to believe, that the problem is the suits brought by the people they injure. They even regard the suits as being frivolous in a world where only a fraction of 1% of patients with legitimate grievances can get a lawyer (see Studdert). Yet they give patients no other way to respond and then try to outlaw that one.

How out of touch with your audience can you be?

Patient-friendly Rule

Here is how unfriendly and out of touch medicine is. Patients cannot even find out about cost ahead of time, let alone quality or safety (for a quality example click "Two Arms, Two Choices" which links to another site). How about taking one small step toward addressing one part of the problem by passing a rule that empowers patients in the simplest of those areas - a rule that requires health care providers to quote on services when asked to?

Did you ever call a hospital and ask how much an MRI is going to cost only to be told that they don't know? You can end up with a bill for thousands of dollars when someone else could have done the job for hundreds. Patients cannot make intelligent cost-benefit decisions without being able to shop around to get reliable information about the costs (and quality, but one thing at a time).

Normal Business Ethics

Home remodeling contractors are required to give firm quotes on work to be done. Why shouldn't medicine be required to as well? If a building contractor can tell you how much it will cost to add three rooms onto your house, a health care provider can tell you how much it will cost to provide a service he/she has done a thousand times before.

Without that it is like doing business with a gang of thugs.

After getting that why not get some insurance company to create a policy that gives lower rates in exchange for accepting a sliding co-pay that rises with costs, not punitively, only enough to make it so that patients care about what things cost so that they will shop around?

It would be nice, someday, if we also could start keeping track of where care is better and where care is worse, so that price is not the only information on which to base decisions. But let's not reach for too much at once.

[People in medicine continually insist that it is impossible for patients to evaluate safety and quality. They are right as long as they are the only source of information about it because they never have and never will record the information that would make that possible. Fortunately, it is possible for patients to get it from themselves, as a group, if the right mechanisms are in place.]

Blinders

The well meaning people at the top never can be well meaning enough to do the job that patients will do for themselves if given the opportunity. The people at the top usually don't even understand how poor of a job they are doing. In Boston, do you think the regulators understand how much better street performers are when they don't have the life squeezed out of them? The people in charge earn their livings by being in charge. Like most people, they probably believe that they are doing as good a job as can be expected. When did a dictator ever not think that? Just like the people running medicine right now with its outrageously high rates of unnecessary death and injury and personal bankruptcy.

Did you see the study in the New England Medical Journal (Nov 2010) that found no progress in safety in hospitals? Like that was news? Well, to people in medicine it appears to have been news. And it appears it will be news to them again the next time a study determines that because I couldn't find anyone in medicine who believed it this time.

Your Caregivers Do Not Know

They do not know that their safety initiatives are created by people whose first interest is protecting providers.
They do not know why patients need to know things like success rates and failure rates.
They have no idea what happens to the patients they injure.
They seldom even are aware of how many patients they injure, personally or as a group.
They have no idea what the worst problems in medicine are.
They have no clue why putting risk management in charge of the oversight of patient safety defeats any initiative they produce.
They do not know that voluntary reporting means no reporting.

The list is too long. I finally created a page of myths believed in medicine.

Their belief in themselves overwhelms any effort to recognize the problems in medicine, let alone fix them. They tell me they don't believe such studies. They have seen progress with their own eyes.

Their Own Eyes

It's that same old problem. With their own eyes. As though they are objective. As though their self-interested group-think and herd behavior do not filter what they see with their own eyes in self-serving ways.

The lead author of one study, Dr. Christopher P. Landrigan of Harvard Medical School, says that voluntary reporting "vastly underestimates the frequency of errors and injuries that occur." That there are people in medicine who do not already know that (I can't find any who do) shows how self-serving the blinders and filters on their perceptions are.

We cannot rely on their good will to make us safe when we cannot rely on their perceptions to be lucid. We cannot educate them into it. We cannot regulate them into it. It has been tried and tried and it hasn't worked. Just look at how the government tried with radiology (see mammography).

Live and Die by the Audience

The only way things will improve is if patients are able to learn where things have not improved and go somewhere else. Otherwise, all the commitment and all the regulation and all the education of all the people in medicine comes to little. Anytime something goes wrong "you can't let one patient ruin your whole career" rationalizes the cover-up and the continuation of the practices that caused the problem in the first place. Not until patients stop coming will it matter enough to caregivers to make patients safe.

For patients to know enough to stop going to where it isn't safe requires gathering information that no one in medicine will report. The negative information is so ubiquitously covered up that providers don't know it themselves. We will have to get the information elsewhere because they will never give it to us.

The study by Landrigan in the New England Journal of Medicine also found that about 18 percent of patients in hospitals were harmed by medical care. That means there is almost a one in five chance of getting harmed if you enter a hospital. If you enter a hospital 5 or 6 times in your life, there is a 100% chance of getting unnecessarily harmed.

The study also found that 2.4% of the time the harm was great enough to cause or contribute to a patient's death. This is how well patients are taken care of in the current system. And now Obama wants to add a truckload of rules and regulators into the mix.

Franco Already Tried That

This is what happened to food in Spain under Franco. Franco mandated industrial methods intended to feed the population cheaply (like what Obama is trying to do in health care for patients). The result was Spain becoming known for having the worst food in the world. When Franco died, inspired chefs broke free and now Spain is spoken of as possibly having the best food in the world.

Franco’s goal was to feed the entire population cheaply. He governed the food industry instead of letting artisans govern themselves. Artisans can govern themselves when the recipients of services are capable of deciding where to go and how much to pay based on honest appraisals of cost and quality. Medicine is dedicated to destroying the information necessary to make such appraisals, and is in denial of that. Obama thinks Franco style regulation can fix that, which shows how little he understands the problem. His results will be worse than Franco’s. At least under Franco there was enough food, even if it was bad food. Under Obama, there is going be rationing in addition to bad care.

An article in the New York Times in October of 2012 said that a survey of 13,575 doctors from around the country found that over the next several years 50 percent of physicians plan to reduce the access patients have to them (rationing). Some physicians plan to avoid the direction medicine is going by refusing insurance and accepting only cash payment. This already is happening in New York.

Description is Prescription

Government is trying to protect patients from a health care industry that does not appreciate the scale of the downside of the care they dispense, that does not know how often they injure patients, and that doesn't know what they do to patients after they injure them. They are not just unaware, they are in denial. But what didn't work for Franco isn't going to work here either.

Medicine keeps telling us that they can solve this, that they mean well and know what they are doing. Neither of those things are true now and never were. For more than ten years I have been writing that the path they are on is nothing short of silly. Their faith in themselves will keep it that way forever - absolutely forever - as long as they are the source of all the information and authority. They don't know that. They don't even know what they don't know. They are not even aware of how and what they think. Fortunately, they don't have to be for the rest of us to climb out of this mess in spite of them, as I explain on this site.

Once government passes a law or institutes a program, it is forever. These thousands of rule are going to trap medicine like amber on an ant. Medicine needs to change and learn and grow in ways that it won't be able to.

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Notes for future work on this topic.

The rise in medical costs accelerated in 1966 with the onset of Medicare and Medicaid. The problem was so obvious so quickly that within a year President Johnson held the first National Conference on Medical Costs. Only a few years later President Nixon called health care costs “a major crisis” and vowed to “reshape the system" to fix it. Has anyone ever run for President without saying that we have to do something about gasoline prices? Has any president ever improved them? Why don't we learn from history? Why do we think every politician who comes along can try the same thing, only bigger each time, and have something different result this time?