Wednesday, April 27, 2005


Ah! New Jersey!!!

I have medical licenses in three states, New Jersey, North Carolina, and Pennsylvania. Every year I must renew my licenses. North Carolina and Pennsylvania send me a letter a few months in advance of the renewal date to remind me to go on line to renew. The renewal process is nearly identical for both of those state licenses: click to verify my demographics and answer a few dozen questions, enter credit card info and then I am done for the year.

For New Jersey I receive a pre-pre-application application in the mail which I must return in the mail. Months later I get the pre-application, asking more questions, which I return in the mail. A few days before the date of renewal, in years past, I would get the actual renewal application which was due back several weeks before it was mailed to me. I sent it back, every year, faithfully, with enclosed check. Like all other physicians in the state, I would actually have my renewed license months late. This, of course, wreaked havoc on all the institutions in which I practice, who require, by their bylaws, a prompt renewal of my license.

This year, after the pre-pre-application and the pre-application, today I received notice that this year we can renew ON LINE! The letter explaining this was difficult to understand, but I eventually figured it out.

Going to the website, I noticed that there was nowhere to click "online renewals" as instructed in the letter. I eventually found a renewal button to click. As soon as I did, there was a banner informing me that contrary to the letter's instructions, the website would not be available for another week.

Ah! Only in New Jersey!

Monday, April 25, 2005


Managing the mundane

This is the BEGINNING of my primordial Medicare Rant.

Like many government programs, Medicare was started as a good idea. In the 60's the costs of medical care were slowly rising and the brunt of medical costs were for the care of hospitalized elderly. The government recognized the plight of the income-limited elderly and they created a safety net program to cover the excess costs of medical care.

From that good idea arose the nightmarish quagmire that exists today.

The first problem that arose was price inflation. To understand the impact that Medicare had upon the cost of medical care, we need first understand the prior impact that private insurance had on the cost of medical care.

Prior to the 50's medical insurance was rare. It became popular after WWII when the government, in an effort to support the economic growth in the post-war years made it advantageous (via tax breaks) for companies to offer health care insurance to the workers as part of their compensation package. Health care insurance became popular. It was called "Hospitalization insurance". It covered a percentage (about 80%) of the cost of hospitalization. For working men and their young families this usually came down to catastrophic illness and surgery. This led to the unregulated rise in the cost of hospitalization and medical procedures, almost exclusively surgical procedures. Despite the rise in the cost of hospitalization and surgery, medical care remained a reasonable expense and was not a burden on the individual and was no burden of the federal budget.

Medicare covered the hospitalization and the outpatient costs for the elderly. Here was a population that REALLY consumed medical resources. The think tanks that budgeted Medicare vastly underestimated the costs of this program. In the first years the actual expenditures were over 300% of what was planned. Every year they increased the budget to account for the previous years vast shortfalls, and still the cost rose at ballistic rates. Surgery and hospitalization was compensated, no matter the cost. Primary care was neglected. The gap in physician fees became vast, surgeons and hospital specialists earning ten to one hundred fold the fees of generalists and pediatricians.

Private insurance companies began to use the Medicare plan as a model.

To contain the costs the government added more and more controls. The controls became nonsensical. The private insurers followed suit.

The Medicare managed Care debacle and the Relative Value Scale disaster will be fodder for future blogs.

In time Medicare has risen to be the largest insurer of all time. It is managed by private companies on a regional basis. The rules dwarf the IRS code by over one hundred pages to one. The administrative costs of Medicare are now almost seventy five percent ( $0.75/dollar!) Medicare makes up one third of the Federal budget, and increases yearly. Since 1980 the cost of Medicare has exceeded the defense budget and is now nearly twice as large.

But remember, three-quarters of the Medicare budget is administrative.

With the regulations being so vast, no one on the planet understands them all. No one has ever actually READ them all. New regulations are promulgated every day, often revoking or altering regulations formulated just days or weeks before. I am blessed to receive e-mails with every change. I have received over one hundred such e-mails in the last six months, many with multiple notifications.

The Medicare rules do not dictate what can or cannot be done. They dictate what will be paid for what is done for what reason. And they dictate how one must submit the information to Medicare.

It is ESSENTIAL, apparently, that SOMEONE in the government needs to know exactly what the diagnosis is for every procedure done, and that it be coded according to the AMA's copyrighted code, the ICD-9. The ICD-9 is a markedly imperfect coding schema, essentially useless. This will be the subject of ANOTHER blog. The procedures performed must be coded according to another AMA copyrighted code , the CPT. Of course, everyone must pay the AMA for the use of these copyrighted codes. (Yes, the inspiration for yet another future blog!)

In any case, if the regulations allow a procedure for a certain diagnosis, then the government MAY pay for it. Anything done to KEEP one healthy or for early detection of occult disease is REJECTED, unless it is politically necessary for it to be reimbursed (like a flu shot, which is reimbursed at a fraction of its actual cost).

That's enough for today.... Stay tuned!

Tuesday, April 12, 2005


the needs of the one.....

The current national buzz about "eminent domain abuse" has come to my little town.

legal dictionary:
eminent domain: the government act of converting privately owned land into public land, subject to reasonable compensation.

Eminent domain abuse occurs when the land is appropriated for one use and then used for another, OR if the land is appropriated for inappropriate non-public use, OR if the compensation is not just and reasonable.

My family were the victims of eminent domain abuse when my grandfather's farm was appropriated. It remains perhaps the deepest wound I carry with me. (Click on the link in My Links for all the details)

But we are NOT going to discuss eminent domain in this blog today. Nope. We are gonna talk about Star Trek philosophy!

In Star Trek III, The Search for Spock, the crew went back to the Genesis Planet to recover him. "Why?", asked the regenerated Spock.

"Because the needs of the one exceed the needs of the many!", enigmatically replied the captain.

I believe that that statement holds the key to the salvation of our race and the repair of the world and the restoration of the dignity of civilization.


Here is how it works:

Each individual, each "one", is precious and special. Any grouping of individuals is
a "many". The many has an existence separate from the ones who comprise it, it is a conglomerate with its own needs and goals.

When the conglomerate acts counter the the needs of ANY one, then the needs of EVERY one are at risk and may be sacrificed at any time. If they MAY be sacrificed, in time, they WILL be sacrificed.

When individuals band together with a common goal, they create a many, a conglomerate. They give birth to an entity with a life of its own, independent of their individual lives. Unless designed with an utmost sanctity for the individual components, the conglomerate will eventually consume them.

The most benign of structures (like the United States, founded on "rugged individualism") or the most holy of purposes (those of organized religion) will eventually sacrifice individuals and eventually all its component members to the "needs of the many", UNLESS ....

Unless the "needs of the one" are sacrosanct and inviolable.

Alternative solutions to public dilemmas -- one less bridge, one less road, one less dam, one less mall, one less school -- may be necessary. One less soldier, a thousand less soldiers, no more wars..... may be possible. There will be less progress, less speed. There will be (get this!) less "entitlement" and more community.

If I lose my rights because of the perceived needs of the group, then we all lose our rights. If you lose your land because the community thinks it needs the land, we all lose our land. If the nation allows one individual to be lost then we are all lost.

If the many exist only to preserve the one, the ones, EVERY one, then we are saved.

Tuesday, April 05, 2005


my little town

I love my little town. My parents grew up here. I grew up here. I returned here to live over twenty years ago. I moved my medical office here. It is a nice, sweet, gentle little town.

There are really high property taxes as there is no significant industry in the little town, and only one main street business district. Owning my home and my office means I get to pay a lot of taxes.

The current administration in town is working hard to improve it. There is a "Main Street USA" project and a "Business Improvement District". There are plans to spruce up the business district and make it classier.

Somehow, when the plans for the Business Improvement District, "the BID", were made, my office, a block off of main street in a residential area, was included. Later, a special tax was levied on businesses in "the BID".

When this became clear to me I made some inquiries as to what plans they actually had to improve my locale. I got no answer. As time went by I wondered if other professionals were included in "the BID" and the special taxation. I asked: I got no answer.

I have been more aggressive at asking the question of all the officials involved. The questions I ask are few and simple:

(1) If I am in the BID, what is in it for me?
(2) If there is nothing special for me, why am I in the BID?
(3) If there is nothing special for me, but there is some nebulous value meant to accrue to all professionals, why tax me and not all?

These questions seem simple. This is a small town. I love this town. Why can't they answer simple questions?

Saturday, April 02, 2005


the anomaly of tenure

I just read this article: - NELC to suffer the loss of key language professors

In essence, The University of Delaware lured, from Yale University, with the promise of TENURE, a spectacularly successful teacher.

As far as I know, academia is the only "industry" that offers tenure. Other industries offered tenure-like job security in times recently past. Seniority was tantamount to tenure. Surely, if one worked well and reliably at a job then there was a tacit expectation of JOB SECURITY.

Now, with changes in societal mores and "corporate culture", no job is secure. Except the job of the tenured professor.

I have heard it said that "tenure" was invented to protect the venerable professor from expulsion from his job when, with the accumulation of knowledge and wisdom, he would take a stand that upset the status quo. Thus, tenure protected academic freedom.

I suspect this is apocryphal. Tenure more likely just gave job security to the aging member of the academic fraternity, awarded by the elders in the fraternity to their rising crony, and supported by the youngers with the expectation that they would get theirs in good time.

Would academia be better without this job lure? How would professors fair as "free agents"?

I understand that there is a glut of Ph.D.'s today. It seems it is becoming a "buyers market". Perhaps academia will soon follow suit and do away with this last bastion of job security.

Other industries COULD offer tenure to employees if they wished to do so... but they do not. Indeed, they have apparently abandoned all pretenses of commitment to employees in the current ethos. Would Corporate America be better if we tenured our most experienced workers?

I wonder if institutions that can be expected to stand by their employees would thrive in today's world. I wonder if the culture of today's world would change if that were so. Would the productivity and the very PRODUCTS change if the expectation of the role of the worker, from line-worker to cubicle-resident to ultimate leaders shifted to reliable commitment of the organization towards them?


beeps and boops and things that go bump in the night

When I was a small boy and visited the hospital I was in awe of the gentle silence that prevailed. The signs on the street outside the hospital admonished "SSHHHHH!!! Quiet! Hospital Zone" The nurses glided silently down the halls in their crepe soled shoes. There was a gentle, restful, peaceful, quiet. The nurses smiled and talked in hushed tones. The very air felt quiet.

Around 1970 the BEEP was invented. Electronic devices were introduced into the medical world and have become ubiquitous. Every vital sign and activity is monitored and every variation is marked by a bleep, beep, boop, or incessant EEEEEEEEEEEEEEEEEEEEEEEEEEEEEE! It is often hard to tell what each noise means among the cacophony: is it the IV line that is malfunctioning and sounding the alarm... or the patient's heart?

The beeping is so everpresent that the nurses become immune and are likely to allow the beeping to continue for minutes or even hours before checking the cause and attending to the "alarming" situation. Savvy patients watch how the nurse silences a device's alarm and then they silence it before the nurse arrives and thus the averse situation is never noted.

But the beepbleepboops are not the only noise pollution in the modern hospital. The culture of quiet has gone, so doctors and nurses and hospital staff speak loudly and a lot. There is no more SSHHHHHHH!

But the most disturbing sounds are the sounds of construction. Thirty years or more ago, a decade would elapse before there would be a renovation or new construction in a hospital. Today, construction and renovation is continuous. There is no day that the jackhammers are not demolishing and the drills are not whining in some part of the hospital. Is progress (er... "progress") so swift today that the physical plant is always in a state of change and expansion?

I believe that quiet was better and that we have lost a valuable piece of the healing arts in our noisy hospital world.

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