(Off Broadway diary trial....)
You live in McAllen, Texas, and you got insurance. You still got cash for co-pays. You can get more meds.
Heart, Big C, diabetes... for what ails you.
You're going to fight yer chronic disease. Take it to the mat.
First problem, find somebody... who knows somebody. A Big Feeder.
Your community, your affinity group... you do find Big Feeder... who gits you to Dr. Bernie Madoff.
You can enter the Golden Offices.
You're grateful... get yer cheeks onto Bernie's hot exam table.
After the interview Dr. Bernie looks over to his office drudge and says:
Give Bertha her weekly appointments through next May.
Send her to our hospital for tests.
She's family.
HCR reality. Medical slavery, Defense Against the Dark Arts, and how the Bernies also conquered Florida, Louisiana, and California -- BTF :::
This is about criminality, not capitalism. American medicine is blowing out the basic economic models without a hint of market interactions.
Our Dr. Bernie Madoff scores marks who are acting out of fear.
Same as the real Bernie Madoff scored marks who were afraid of dying broke.
There is no medical S.E.C. Not even an incompetent one.
Where things go crazy -- the McAllens, the Floridas, Texas generally, Louisiana, California -- market capitalism has no connection to what is going on.
Prior to reforms in the current Senate HCR Act, the GOPers had blocked any and all efforts to control medical criminality.
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Stefano Fenoaltea developed an influential model of forms of slavery at different places in history. He relates levels of supervision required for different tasks, along with means of coercion, to patterns of slavery.
These medical slaves do what they are told, generate profit, and the supervision costs are minimal. Perfect. Blows out anything Fenoaltea could have dreamed up.
Never underestimate American ingenuity.
These medical marks act under threat of pain and death. But they don't seem to mind it. They say that they are grateful....
Go figure.
Its as though our Dr. Bernie Madoff could run a fashionable Slave Shop in Charleston in 1810 and have young strapping Africans walking in the front door, offering themselves into bondage. He doesn't have to capture them in Africa. He doesn't have to transport people across the Atlantic. He doesn't have to waste years in Jamaica getting them beaten down.
These "slaves" go where the feeder-referral chits send them. No force required to keep control.
These "slaves" think that they are among the lucky few who get our Dr. Bernie Madoffs to take their business.
There's more "slaves" walking in every day. A similar number die, here and there. Its laissez faire.
Slavery is nominally illegal, today.
There is no reason to kid ourselves. Slavery is and will always be the Numero Uno mechanism for maximizing return from human resources. When laissez faire Reaganomics take hold, expect to see almost anything.
Unrelenting Conservative Spirit -- a rightie synonym for lawlessness.
Do consider the plight of Bernie Madoff's victims -- perhaps 5,000,000 of them ruined, counting in the retirement plan victims. The illusions fostered by Bernard L. Madoff Investment Securities come across as evil.
We see the same impacts with our Dr. Bernie Madoffs and their excesses. The bankruptcies. The being driving from pillar to post. America's 133,000,000 chronic care patients are driven to hundreds of thousands of bankruptcies. They get far too much treatment, too many drugs which worsen medical outcomes.
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Medical excess does not happen at the University Hospital Centers. Not at Mayo Clinic. Not VHA or TriCare. Certainly not at the Kennedy CHCs.
What causes a local cost explosion ??? What is it that makes for dysfunctional excess at a medical practice ?
That takes some detailed analysis.
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The statistical Ph.D. crowd had no idea what was going on, until longitudinal studies of the aging found that much of what older people were doing was going to the doctor. A dozen different doctors a year. Also, that hypertension and enocrinological conditions get tacked on everywhere -- multi-condition chronic care have expanded to 75,000,000 patients/marks/"slaves."
Defense is possible.
Be a veteran and go to VHA. Go to a Team Model system, like all of the UHCs. Go to KP. Go to a Kennedy CHC.
Do a program that trains for self-management of chronic conditions.
Stanford's Chronic Disease Self-Management Program (CDSMP) is a good start.
Certainly: get an independent review of your prescriptions:
...One of my senior friends on Kauai was failing.
There wasn't anything about her health that was obviously killing her but she was sliding down hill. She went to the hospital when she had trouble breathing because she was developing congestive heart failure.
A doctor reviewed the 12 or so medications she was on. He cut it down to just a few meds. She got better.
The drugs were killing her.
-- comment from FishOutofWater on Tue Dec 29, 2009 at 05:24:19 PM EST
It is difficult to take more than 3 or 4 drugs over time without risk of killing yourself.
The few exceptions have to do with such as throwing multiple antibiotics at such as a severe sinus infection -- a crisis event.
The longitudinals dug it out that multi-condition chronic care patients have been averaging 12 different doctors and 50 prescriptions a year.
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The mechanisms of our Dr. Bernie Madoff example parallel a number of aspects of the real Bernie Madoff Ponzi scheme.
There was no actual investment at Bernard L. Madoff Investment Securities. You can't seriously blame buying stocks on NYSE/NASD for what Bernie Madoff pulled off.
Of course, people do get medical treatment at the Dr. Bernie Madoff extended interlocking practices.
However, the clear majority of the procedures and medicine handed out off feeder-referrals are not medically indicated. The most of the activities that go beyond standard care, are aimed to generate billing and do nothing or worse for the patients.
Bingo, bingo, bingo
Its the referrals.
I've said elsewhere, there's a doc I knew at the hospital where I used to work; every patient he admitted got no less than 3 referrals, and those specialists were, of course, incentivized by the reimbursement system to do something to the patient; whether it was for the patient could be left to interpretation. But these specialists were also far, far more likely to refer patients back to this primary care doc.
Not to mention that every Medicare patient he saw in his outpatient office had a heart murmur, so they all got echocardiograms, done in his office, billed to Medicare. But since the codes matched, Medicare doesn't catch it, becase they don't have sufficient oversight.
That's just a one-man example of the craziness of the system that Atul Gawande depicted in his article in the New Yorker last summer. And just one provider in one city.
-- stitchmd on Thu Dec 31, 2009 at 04:58:00 PM EST
Analysis of America's dominant medical feeder-referrals scheme presents as the 800-pound gorilla of medical economics.
Say what you will, generating $500-billion to $1-trillion of legal claims with a form of slavery is a unique invention.
The analogy to Bernie Madoff is doubly interesting. It was actually Madoff who copied the medical system, not the other way around.
Bernie copied the doctors, then perfected the setup with feeder-specialists feeding specialists feeding feeder-specialists feeding specialists.... To no end.
Bernie Madoff got his Ponzi scheme to work for two main reasons:
-- He got himself vetted by NASD, then by Mr. Shapiro out of Boston, then the most of the West Palm CC, then Hollywood royalty
-- His feeder network took on a life of its own. Fairfield Greenwich Group, Oppenheimer Funds, S & P Investment Group, BNP Paribas, Austin Capital, Stanford Capital Management, Bank Medici, Tremont Group Holdings, Rothschild & Cie, Gabriel Capital, Sumitomo Life Insurance, and many more.
He and his wife gave $240,000 to political causes, with the most of it going to the Democratic Party. $25,000 a year from 2005 through 2008 to the Democratic Senatorial Campaign Committee.
Hip-hip-hooray !!
Bernie did not waste his marks' money on Ralph Nader.
Dr. Bernie Madoff is able to double and triple his group practice total-annual-billings -- beyond medical norms. We'll do this for fun, but there's a lot of truth to these two reasons:
-- Dr. Bernie got himself vetted by graduating from Harvard and/or Hofstra Medical school. Served as Chairman of something very AMA-ish. Sheepskins on the wall. Board certified. Ensconsed at the always grateful Local University. He is a competent doctor.
-- His feeder network has a life of its own.
Twelve G.P.s drumming,
Eleven Internists piping,
Ten hematologists a-leaping,
Nine obstetricians dancing,
Eight gastroenterologists a-milking,
Seven oncologists a-swimming,
Six rheumatologists a-laying,
Five cardio rings,
Four calling psychiatrists,
Three French podiatrists,
Two turtle doves,
And a partridge in a pear tree!
Dr. Bernie gives vast sums to the political parties.
Dr. Bernie out-sources the task of changing cage paper for the doves and the partridge.
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The names on the chains can be a little odd.
Cardio -- most common denomination. 17,000,000 people in the lists, $165-billion a year generated as gross revenue. $10,000 a person.
The best chronic care for cardio is available at VHA. Best outcomes and patient satisfaction. We're talking $4,000 a person -- optimal treatment.
The alternative to VHA or Mayo is too many drugs and too much exposure to other patients with contagious diseases.
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The arguments (private payer vs. public option) miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes.
-- Gilles Frydman
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Consider McAllen, TX. Their Dr. Bernie Madoffs cost Medicare fifteen thousand dollars per patient. The worst anywhere....
-- El Paso County, eight hundred miles up the border, has essentially the same demographics. Both counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed. Yet in 2006 Medicare expenditures (our best approximation of over-all spending patterns) in El Paso were $7,504 per enrollee—half as much as in McAllen. An unhealthy population couldn’t possibly be the reason that McAllen’s health-care costs are so high.
-- In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.
--"It’s malpractice," a family physician who had practiced here for thirty-three years said. "Come on," the general surgeon finally said. "We all know these arguments are bullshit. There is overutilization here, pure and simple." Doctors, he said, were racking up charges with extra tests, services, and procedures. The surgeon came to McAllen in the mid-nineties, and since then, he said, "the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ "
Atul Gawande, The New Yorker, The Cost Conundrum / What a Texas town can teach us about health care
Americans dearly believe that more is better.
But ask the Mayo Clinic. Medicare at MC is in the lowest fifteen per cent of the country — $6,688 per enrollee in 2006. Eight thousand dollars less than getting crappy health care at McAllen.
Katherine Baicker and Amitabh Chandra found that the more money Medicare spent per person in a given state the lower that state’s quality ranking. The four states with the highest levels of spending — Louisiana, Texas, California, and Florida — were near the bottom of the national rankings on the quality of patient care.
In 2008 we had 65,000,000 surgeries performed. That far out-strips the surgeries performed in every country that outperforms us for overall health outcomes.
Of course, we had 200,000 deaths from surgical complications....
Less is more. With Mayo Clinic defining the practical limit.
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O.K., summary time.
I'll admit it. $500-billion is wrong.
Compare our $2.4-trillion medical disaster to the Mayo Clinic model in MN and what Mayo does in Florida. The feeder-referrals and medical overuse scams add more like $750-billion or $1-trillion-a-year to American medical costs.
We spend $2.4-trillion total. That is by far too much. Maybe $1-trillion than you want to spend to optimize medical care. (The extra $400-billion is normal office calls, preventive medicine, patent medicines and such.)
We kill 45,000 by withholding medical care.
We probably kill 250,000 by doing way too much to the Bernie "slaves."
Chronic care and acute care should run about equal.
We know what competent care should cost. Mayo Clinic is a perfectly good model. The Kennedy CHC clinics are going to be aimed to work like tiny Mayos.
The 133,000,000 chronic care patients are reduced to a de facto status that approximates chattel slaves. For the parts of their lives that connect to medical care, there has been no one on their side.
What we need to see is adult oversight. Management.
Cost controls on a sensible basis for insurance and for Medicare. (HCR Act... a start.)
Letting doctors participate in profits from hospital tests that they prescribe ??? That is simple conflict of interest.
Expanding the Kennedy CHCs (FQHCs) to 14,000 sites and 45,000,000 people is the strongest alternative for getting health care to uninsured and underinsured.
We get a solid EMR with standardized VistA/WorldVistA for the CHCs, that is a solid goal. Indian HS is a first-rate proof-of-concept example for such an expansion. CHCs also need some of the IHS code.
Then we can budget another $6-billion for remote medicine -- clinics and testing tools on wheels -- and reach a total of 60,000,000 people.
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The Dr. Bernie Madoffs ??? Screw 'em.
They're crooks and they know it. Everybody in medicine and economics and politics knows it.