If I Were Dictator

>> Tuesday, June 16, 2009

You know what, I'm glad I'm not Obama. And not just because every citizen in the country (and several others) think they can do the president's job better than he can to nearly the same extent they thing they can all design a better space program.

I appreciate the notion of being in charge and wanting to clean up a big mess just because the mess is overwhelming (which may or may not be how he sees it) and bothering you. I saw a couple of articles today about the challenges Obama faces with healthcare not because he does or doesn't have a good notion about how to go about it, but because he can't just dictate it and make it so. It's more or less a democracy so he needs a consensus a majority of people in Washington to agree with him. The first one I found in (*gasp*) the New York Times. The second one was forwarded to me by the Mother. Oddly, I think I walked away with something entirely different than she did when I read it.

One of the down sides to democracy is you rarely get the the right change the first time - because you have to water it down to get anything past those that want the status quo. You tweak and weaken in order to appease this group or that knowing that, if you weaken it too much, it's worse than nothing. Those who want it to fail will use it's failure as an excuse to put of meaningful change a little longer.

So, what would I do if I were dictator (because, take it from me, I don't have the diplomacy or charisma to get anything past people who don't want it - I either beat them down with data or I fail)?

I'm glad you asked.

(Again, this is from the back and forth between the Mother and myself - give her any credit you care to; I can take the blame. I've embellished a bit since the conversation, too).

Here's what I thought...

We address the health care cost issues I mentioned yesterday: tort reform, subsidizing medical education, support electronic recording keeping, and, since I'm a dictator not a politician, set up a single payer system (in conversations with the Mother, I was talking about a public option, but, hey, I'm in charge now).

One of the things I've seen successful in my 20 years working for the government are something called FFRDC (Federally Funded Research and Development Center) organizations. Funding with usually federal funds:

An FFRDC meets some special long-term research or development need which cannot be met as effectively by existing in-house or contractor resources. FFRDC's enable agencies to use private sector resources to accomplish tasks that are integral to the mission and operation of the sponsoring agency. An FFRDC, in order to discharge its responsibilities to the sponsoring agency, has access, beyond that which is common to the normal contractual relationship, to Government and supplier data, including sensitive and proprietary data, and to employees and facilities. The FFRDC is required to conduct its business in a manner befitting its special relationship with the Government, to operate in the public interest with objectivity and independence, to be free from organizational conflicts of interest, and to have full disclosure of its affairs to the sponsoring agency. It is not the Government's intent that an FFRDC use its privileged information or access to facilities to compete with the private sector. However, an FFRDC may perform work for other than the sponsoring agency under the Economy Act, or other applicable legislation, when the work is not otherwise available from the private sector. [Per Federal Acquisition Regulations System (FAR) 35.017(a)(2)]

The Jet Propulsion Laboratory is effectively one for NASA and DoD has a number and so does the Department of Energy. They are generally conglomerates of highly trained, highly skilled individuals who provide objective evaluation and assessment for contracts, do testing, etc. for different government departments, without the politics, without the profit motive. Because of the nature of their business, we have to have a secret clearances and demonstrate that they have no conflicts of interest - that means no kickbacks from special interests, big pharma, anything. If they get more money from the government than they need, they pay back the extra. They are expensive per hour, but tend to be so efficient (because there's no incentive for waste and they are top notch experts) that it works out to be cost effective.

Now, what if, instead of a government entity, one set up a single payer system as a not-for-profit. You hire doctors and insurance experts built up a current successful FFRDC structure with only a skeleton admin support staff (Some companies have a subject matter expert:admin ratio of ~1:10 - good luck finding that elsewhere) . 100% of "insurance" fees (or healthcare taxes) collected go out to pay for medical care. If they pay out less than they take, fees go down. If they pay out more than they take, fees go up. But this part of it costs the government nothing – care and fees are always the same. The government only pays for the salaries of the employees. Any reimbursement of fees for the poor – that’s done elsewhere by the government. That reimbursement and the salaries are all the government pays for. The doctors/experts on staff are prohibited from any financial ties to institutions or drug companies.

Payment of fees for doctors are agreed between my fictitious not-for-profit and the doctor/hospital (and we have an option for a salary for X number of people or fee for service – I’m not an expert so I don’t know which is better, but, if I was dictator, I'd let them argue it out and decide). The treating doctor enters a diagnosis and a treatment electronically; standard treatments are automatically approved (within seconds). If it's something out of the ordinary, a corresponding doctor expert on call for X doctors must respond within minutes with approval or questions for clarification. If accepted, the treatment is performed and the doctor is paid by close of business that day. No forms, no mess, and the potential doublecheck keeps everyone honest and forces the doctor to think about what he’s doing and admin is minimized.

Ideally, electronic systems would have popups letting you know if you’re prescribing something the patient is allergic to (as has happened to me, even though I answer dutifully each time I go to the office) or other conditions the doctor needs to know about (PREGNANT! As has happened to me, even though I informed everyone, including the doctor, that I was).

Because all of the information is in a large database, trends, secondary infections, botches, relapses, etc can be tracked. Ideally, you'd take a random sampling of patients and quiz them about service and success, but the data should match. Their performance is reviewed if, say, they come in over (or under) averages for the region/specialty. My FFRDC would want to make sure everyone is getting the proper care. Again, not necessarily bad--women, for instance, often limit their practices so they can stay home more hours.

This FFRDC can also serve as part of the tort reform as an objective body to review errors and alleged malpractice.

Experimental care is auto reviewed for efficacy and relevance to research.

I could throw in an ethics board (probably separate but interacting with my FFRDC, probably another one), to evaluate such ideas as euthanasia and assisted suicide. When is enough enough. Those ideas will have to come from the top. They might have to be regulated, because the individual patients don't understand the concept, but medical judgment will allow for individual evaluation.


I don't think things will be so simple for Obama.


  • Melissa

    Actually I think he is going to have it pretty easy, just like everything else he had done. He has the majority votes, and it will probably go right through. You have a good feel of how things should work. Electronic dr orders, are something that should have happened long ago, but doctors resist change.

  • Stephanie B

    Obama has had things he wanted passed, but almost never in the form he proposed. In almost every case, key concessions have robbed the bills of much of their power.

    Everyone resists change, not just doctors. I think one problem is that electronic records, with sufficient safeguards to protect the privacy we demand, are expensive and it's one more expense when many doctors are already struggling. I personally think the potential good far outweighs the inconvenience.

  • The Mother

    Okay. Melissa: electronic records are a grand idea, and most doctors support them. But the HIPPA regulations (from the government) make e records exceptionally difficult. Which is why most offices still use paper. That plus, of course, the massive costs to the doc to switch over, which is hard to bear when the practice is barely making it as it is.

    The problem I have with the plan as outlined is that it does NOT address the major costs of healthcare--malpractice, end of life care, etc. It just fiats low costs--and fiats never work.

    If docs are supposed to roll over on this, cut costs, cut unnecessary expenses and procedures, it seems that they should at least get the protection of not getting sued because they DID.

    Putting the cart before the horse is never the best idea.

  • Stephanie B

    The Mother, I think a big part of why any reform is going to be challenging is that most people perceive doctors/hospitals as the problem - cause they're the ones sending the bills. People don't see the insurance money squirreled away as a cost because it's never in their hands, it's taken out of their paychecks and augmented (often silently) by employers.

    Health care costs is bigger than telling doctors: don't do tests you don't need and charge us less. There are reasons they cost so much and reasons why more tests might be performed than necessary (Try telling a patient who's convinced herself she needs an MRI not to get one).

    If steps aren't taken to address the root causes for the high cost in addition to the other changes, the problem won't be solved, we'll just have more victimized doctors and, folks, that means even fewer doctors.

    But, I maintain, sticking to the status quo is not going to do anything but increase the perception of doctors as the bad guys.

  • The Mother

    Granted. All of that.

    But Obama made a pretty big faux pas when, with one breath, he told doctors to cut costs, and with the other, he told them that he would not support tort reform.

    People don't realize how big a problem this is.It's not just the cost of the malpractice insurance and the big payouts. CYA medicine is practiced routinely. There's no getting around it. If it's even REMOTELY possible that you might miss something, no matter how remote, you have no choice but to order the test. There's a reason that I got an MRI every 6 months when I had migraines. NO ONE wanted to miss that brain tumor in a young mother of four.

    But that costs $$$. And telling docs that they have to cut costs, without giving them the tools to do that, is pretty bad policy. And it means stiff opposition from the guys Obama really needs on his side.

  • Stephanie B

    I agree with you, the Mother. I have no idea if Obama does or not but I know the democrats in Congress do not. He couldn't offer it to you because it's just not possible in the first go round. Even if he were willing to champion it, he can't get it without hard numbers proving what you know is true - which you and I know no one can produce because no one can admit to CYA practices. In the news, they still say it only makes 0.5% difference to overall costs - without data to back it, people won't want to believe (and, yes, even though many people demand unnecessary procedures). (Yes, I'm rolling my eyes)

    I know you're right. I know real tort reform (well overdue) will be required before we can get this problem licked. I don't know if it is possible (short of something miraculous) in the first go round. I'd certainly support it (and will dictate it if I become dictator), but I can't tell you it will happen as soon as it should. I wish I could.

  • Melissa

    The mother, I agree I do not agree with every aspect of Obama's plan. Tort reform, and medical malpractice issues must be addressed. He is a lawyer and he should know that. However hospitals, and nursing homes need to start brunting some of the responsibility where malpractice is concerned. Low staff ratios to high patients, is never safe. Giving assignments to nurses who are uncomfortable, or untrained only increase the risk. There are so many issues, for malpractice not just the docs. As for electronic records, it will be no less secure than any other form of electronic filings. It is faster,more efficient, and will cut down on mistakes. If it is too expensive, then they can offer some kind of assistance to get it done, esp since they want it so bad. As for end of life care, I am unsure of your issue because you did not clarify that.

  • The Mother


    Hospitals and nursing homes are understaffed because they are under-reimbursed. If you aren't making enough money to pay your staff, the staff is the first to go. That's the same reason you can never find a clerk in a discount store.

    Electronic records are great. Yes, they will cut out mistakes. But you missed the crux of the argument. The HIPAA regulations that went into effect a few years ago (Health Insurance Portability and Accountable Act) effectively sunk e records for most purposes, because it's virtually impossible to guarantee patient privacy when you're blasting the patient's records onto the web. Only the most lucrative of practices have been able to meet the 20 standards and 36 specifications set forth by HIPAA. Others have simply deemed it untenable until something else happens. Ditto emailing patients--HIPAA standards apply and must be met.

    The end of life issue was part of my long conversation with Stephanie, and she did paraphrase it in her posts. Depending on which study you read and in which decade it was done, 70-90% of health care dollars are spent in that last year of life.

    That's an enormous number. But patients expect that care. I can't count the number of times my husband (who is the one of us in patient care medicine) told a family that further care was futile and potentially painful, only to be informed that he was to do everything possible to "keep grandma alive" or he would be facing a lawsuit.

    We are going to have to lose this mentality. It is simply not done anywhere else in the world--in any nationalized/managed healthcare system, the docs have the final say on when enough is enough.

    And yet, in America, the patients, who are often ill informed and running on emotions, make that call. And they have the weight of the courts behind them. It's the reason that we develop more and bigger and nastier surgeries for pancreatic cancer, in the futile attempt to keep people alive for 6 months instead of the usual 4, two of which are spent in the ICU (and that gets reported as a 33% survival increase!).

    I'd rather be drinking margaritas on the beach. And until the rest of America gets that, healthcare costs are NOT going to come down.

  • Relax Max

    I see in the news this morning that Hillary Clinton fell and broke her elbow. The article said she was treated at nearby George Washington University Hospital. I'm guessing for free, or at least that they didn't make her wait until she showed her insurance card. I'm also guessing she didn't have to wait as long as some of our veterans who are seeking treatment.

    But, sarcasm aside, this brings up another area crying out for improvement, and which perhaps might offer another source of greater economy: government hospitals. (OK, GWUH is not a Government hospital, but you know the ones I mean.) When I say economy, I mean efficiency - not closing needed hospitals and clinics. They are already too far and few, at least in the West. But there is so much there to clean up.

    Okay, sarcasm picked back up again: I wish Hillary well.

    I will still watch our president though. He seems intent on outspending even the Republicans. Wow.

    And, if I ever get an irresistible urge to pay for other people's health insurance, I'll be sure and let you know.

    I guess I already do. Never mind.

  • Stephanie B

    I would love to see affluence and celebrity eliminated as factors in the level and speed of health care and, if you're asking my opinion, I love the idea of government hospitals or any other non-profit hospitals. I have no problem with the notion of providing a decent living for medical practitioners, but it's hard to get behind the notion of people who profit from the suffering of others. (Doctors might very well disagree with me).

    You not only subsidize other people's health insurance (if you're healthy), you also provide profits to health insurance companies and subsidize uninsured people's healthcare. And huge class action malpractice suits. Except, it's pretty untraceable and unregulated today.

  • The Mother

    Obviously, Stephanie, you have never worked in a VA hospital. The waste and abuse would astound you.

    I don't think doctors see it as "profiting" from other people's suffering.

    I think we see it as being reasonably reimbursed for our expertise, educational expenses, and all those years when we were NOT out there making a living.

  • Stephanie B

    You are correct. I never have. Let's not confuse poor implementation with a poor idea. Like my non-profit organization, doctors are paid (and paid well) but costs are directly correlated to costs of facilities, materials and salaries vis-a-vis fees without siphoning off some percentage or portion to make money for those not directly involved. Nor have I ever caviled at doctors and other medical practitioners be given a good return for their years of work and and their expertise and time.

    Can you say doctors always reap all the benefits of the profit from a for-profit hospital? No doubt that is sometimes the case, but it's the need to generate profit among investors and stockholders and business managers that are probably driving the profit margins for many hospital chains and the like.

    When a hospital sends million/billion dollar bonuses/dividends to CEOs, upper management and stockholders, that is someone profiting from someone else's suffering.

    In my opinion.

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