My sister, who is an RN and studying to become a nurse practitioner, recently was required to interview a physician regarding what is known as "evidence-based" medicine. She asked me for perspective.
Here is the question:
The Interview Objective:
To determine individual perspective regarding the significance of research in generating an evidence-based practice for nursing.
Here is my response to her:
Evidence-based medicine is the substitute created by third party payors to replace the traditional boundaries of accepted clinical practice defined by the physician-patient relationship. While the research itself might be useful, the underlying impetus for the research is harmful to the practice of medicine. There will always be outliers among providers, who in a traditional model would likely be marginalized by other providers and by the community itself. With the rise of insurance and government payors and the concomitant weakening of the unique provider-patient relationship dynamic, traditional means to identify substandard providers have been weakened. In general, the American system of health care delivery is excellent, but the brokenness of the reimbursement system will inevitably lead, I believe, to a decline in the quality of care.
Insurance companies are driven not by altruistic motives, but by profit margins, and government by political considerations. While insurors today claim that it's good business to promote wellness and provide thoughtful care, the facts belie their claim. Anecdotal evidence abounds to confirm what is suggested by common sense---that insurance companies prefer to delay and challenge legitimate payments as much as possible. Employers, the traditional conduit for health insurance benefits for the last 40 years, pay insurance companies prospectively on a monthly basis for their employees' health benefits. Meanwhile, in my hypothetical, the insurance company withholds payment for a legitimate service routinely for three to four months. The interest rate "float" generated by this cash flow manipulation must generate millions upon millions of dollars for these companies!
But I digress. The question relates to the significance of the research in generating a particular model of practice. Again, most research is inherently helpful in contributing to the body of knowledge of medicine. Such research has, in my thirteen years of private practice, led to striking improvements in patient care, especially in cardiovascular disease. Examples include the improvement in mortality and morbidity from tighter blood pressure control in hypertensive patients or glycemic control in diabetics. We are currently in the midst of a dramatic increase in the use of statin drugs due to overwhelming evidence of their benefit. All of these treatment trends are beneficial to patients.
Unfortunately, clinical patient encounters resist the precision inherent in the scientific method. This makes quantitative assessment of patient care very difficult, and current methodology is very primitive. It's my belief that an excellent clinician might have, on the basis of a number of unmeasurable variables, poor results in such analyses. Patients don't come to the doctor with Problem X, Y, or Z. They come in as themselves, indivisible, and the art of the clinical encounter is in managing that session to the benefit of the patient. Treatment based on evidence is desirable but incomplete unless it is modified to a patient's particular circumstance. I recently put a patient on an angiotensin-receptor blocker for his newly-diagnosed hypertension, and his insuror resisted paying for the medicine. Evidence-based guidelines would suggest that I use a different and less expensive drug. But I know that this patient is resistant in coming to the doctor in the first place, would be non-compliant with any medicine with even mild side effects or an inconvenient dosing schedule, and his sister and mother developed a cough when placed on ACE inhibitors. His insurance company and the evidence-based reviewers don't care about these things. This is a trivial example but the first to come to mind, and it illustrates in a small way the factors which are encompassed in an encounter.
A provider who bases her practice on evidence-based medicine is an automaton who would miss critical nuances. On the other hand, a provider who incorporates evidence-based practices into a framework of basic science education, clinical experience and compassion will provide superior care. Payors and regulators, however, will not necessarily be impressed. This is one of the major sources of tension in American medicine today. At their core, evidence-based clinical guidelines are a tool for clinicians, but are not an end unto themselves.
End of my response.
I will soon post more on what I believe is a fundamental problem with America's health care reimbursement system. Notice that I intentionally specified "reimbursement." It may be self-serving, but my perspective is my perspective, and I think America's health care system is excellent. However, as I noted above, the health care system is imperiled by a broken payment system.
A note about last night's Republican Presidential Debate. Mike Huckabee again distinguished himself among a host of men who will say anything to be elected President. When I heard his response to a question about evolution, I wanted to (and did) stand up and applaud. Many folks have not taken the time to become familiar with Huckabee, but I urge you to take a look. He is an impressive guy. He has given I think objectively the best performance through all three GOP debates.
Wednesday, June 6, 2007
Sunday, May 20, 2007
Immigration Amalgamation
My plan had been to wait until I'd read the recent bipartisan Senate compromise bill on immigration, until I realized the Senate apparently plans to vote this week before Senators have even read the bill. In fact, even today the final version is not yet drafted, so no one really knows what's in it. If a Senator can vote for something he knows nothing about, then I can certainly opine, as well. Since facts are in short supply regarding this bill, it is useful to look at who the supporters are, and compare them to the opponents, always looking toward the motivation of each side.
Amongst the supporters: the Bush Administration, most Democrats, the U.S. Chamber of Commerce, and some Republicans such as Lindsey Graham of South Carolina. The motivation of the Bush Administration is easy to deduce. Bush has always been a little leftward on immigration, I think because he views it as a demographic plus long-term for the GOP, and also because he really believes his rhetoric. Besides his judicial legacy, with the permanency of his tax cuts in doubt and with the failure of his Social Security reform, immigration reform would be viewed by opinion-makers as one of Bush's major accomplishments. President Bush is human and therefore not immune to such fluff, especially at a time when he is steadfast in the face of ferocious opposition to his foreign policy objectives.
With regard to most Democrats, again, their support is predictable. Most national Democrats will reflexively support any measure that results in increased numbers of low-income government dependent voters, as this bill will. Only the most left-wing radical Democrats would oppose this bill, and then on the grounds that it doesn't let in enough immigrants. Increased immigration fits well into their philosophy of "sharing" and redistributing wealth, and more immigrants means bigger budgets for entitlements such as Medicaid, Social Security, and children's services. Bigger budgets mean bigger taxes and bigger bureaucracy and bigger government--these are Democratic fundamentals.
I think the Chamber of Commerce, along with some other business interests, views this bill as a way to ensure a ready supply of lower-wage workers, especially in service sectors. I'm not in disagreement with much of their reasoning, but, on the other hand, these are the same guys advocating increasing ties with Communist China and who are building factories and business partnerships with the Chinese. Their aim is economic gain, but I can't shake the feeling that in dealing with folks like the Chinese, we are dealing with potential enemies. I fear that 50 years from now our children and grandchildren will face a Chinese threat that we helped fund. Forgive my roundabout process, but my point is that I'm not convinced the Chamber of Commerce has our national interest at heart--they have big business interests at heart, and those two interests are not always concordant.
Finally, there are the Republican supporters of the bill. A few, I think, are motivated by principle, but others are simply interested in favorable publicity or are appeasers always willing to compromise to "make a deal." Lindsey Graham of South Carolina, one of the Republican negotiators, has never met a camera he didn't like, and he is way too quick to sponsor compromises that sell out principles. John McCain typifies this group well. These, then, are the players in support of the immigration bill.
What about the opposition? Amongst the GOP Presidential candidates, most except McCain have come out against this compromise. This tells me that these guys have read the pulse of GOP primary voters and detected real concern. I was particularly interested to see Fred Thompson quickly come out in opposition with a well-reasoned article which can be found on the RealClearPolitics website. Countering the Chamber of Commerce support for the compromise is the National Federation of Independent Business. The NFIB might have been expected to represent the same interests as the Chamber of Commerce, but they have instead come out against the bill because of its punitive measures against small businesses and because of the regulatory burden it places on them.
On balance, just looking at the compromise's supporters and opponents, I'm pretty comfortable in opposing this bill. It seems to me that the merits of a guest-worker program ought to be subjugated to the imperative of securing our national border. Why can't the government come to the American people and say, " We've reduced illegal entry into this country by 80% over the last two years, and every illegal immigrant who commits a felony is being deported. Now that we've secured our borders and established the rule of law, here is our proposal for a guest worker program." This seems eminently more reasonable to me.
I hope conservatives can muster the groundswell necessary to stop this compromise. I'm optimistic that if we can, then perhaps progress can be made in enforcing our current immigration laws. If that happens, then I'm all for hashing out an agreement that allows for reasonable immigration. Right now, though, we're too busy getting the cart before we have a horse. And this is one ugly cart.
Amongst the supporters: the Bush Administration, most Democrats, the U.S. Chamber of Commerce, and some Republicans such as Lindsey Graham of South Carolina. The motivation of the Bush Administration is easy to deduce. Bush has always been a little leftward on immigration, I think because he views it as a demographic plus long-term for the GOP, and also because he really believes his rhetoric. Besides his judicial legacy, with the permanency of his tax cuts in doubt and with the failure of his Social Security reform, immigration reform would be viewed by opinion-makers as one of Bush's major accomplishments. President Bush is human and therefore not immune to such fluff, especially at a time when he is steadfast in the face of ferocious opposition to his foreign policy objectives.
With regard to most Democrats, again, their support is predictable. Most national Democrats will reflexively support any measure that results in increased numbers of low-income government dependent voters, as this bill will. Only the most left-wing radical Democrats would oppose this bill, and then on the grounds that it doesn't let in enough immigrants. Increased immigration fits well into their philosophy of "sharing" and redistributing wealth, and more immigrants means bigger budgets for entitlements such as Medicaid, Social Security, and children's services. Bigger budgets mean bigger taxes and bigger bureaucracy and bigger government--these are Democratic fundamentals.
I think the Chamber of Commerce, along with some other business interests, views this bill as a way to ensure a ready supply of lower-wage workers, especially in service sectors. I'm not in disagreement with much of their reasoning, but, on the other hand, these are the same guys advocating increasing ties with Communist China and who are building factories and business partnerships with the Chinese. Their aim is economic gain, but I can't shake the feeling that in dealing with folks like the Chinese, we are dealing with potential enemies. I fear that 50 years from now our children and grandchildren will face a Chinese threat that we helped fund. Forgive my roundabout process, but my point is that I'm not convinced the Chamber of Commerce has our national interest at heart--they have big business interests at heart, and those two interests are not always concordant.
Finally, there are the Republican supporters of the bill. A few, I think, are motivated by principle, but others are simply interested in favorable publicity or are appeasers always willing to compromise to "make a deal." Lindsey Graham of South Carolina, one of the Republican negotiators, has never met a camera he didn't like, and he is way too quick to sponsor compromises that sell out principles. John McCain typifies this group well. These, then, are the players in support of the immigration bill.
What about the opposition? Amongst the GOP Presidential candidates, most except McCain have come out against this compromise. This tells me that these guys have read the pulse of GOP primary voters and detected real concern. I was particularly interested to see Fred Thompson quickly come out in opposition with a well-reasoned article which can be found on the RealClearPolitics website. Countering the Chamber of Commerce support for the compromise is the National Federation of Independent Business. The NFIB might have been expected to represent the same interests as the Chamber of Commerce, but they have instead come out against the bill because of its punitive measures against small businesses and because of the regulatory burden it places on them.
On balance, just looking at the compromise's supporters and opponents, I'm pretty comfortable in opposing this bill. It seems to me that the merits of a guest-worker program ought to be subjugated to the imperative of securing our national border. Why can't the government come to the American people and say, " We've reduced illegal entry into this country by 80% over the last two years, and every illegal immigrant who commits a felony is being deported. Now that we've secured our borders and established the rule of law, here is our proposal for a guest worker program." This seems eminently more reasonable to me.
I hope conservatives can muster the groundswell necessary to stop this compromise. I'm optimistic that if we can, then perhaps progress can be made in enforcing our current immigration laws. If that happens, then I'm all for hashing out an agreement that allows for reasonable immigration. Right now, though, we're too busy getting the cart before we have a horse. And this is one ugly cart.
Thursday, May 17, 2007
Debating the Debate
This week's GOP debate in South Carolina was another opportunity for the top tier guys (McCain, Romney, Giuliani) to distinguish themselves from one another, as well as an opportunity for the lesser-known candidates to kindle an identity for themselves in the public eye. Unlike the earlier GOP debate, I did not watch this one in its entirety, but I've reviewed partial transcripts and viewed snippets and digested some snap post-debate commentary, and, having done so, I feel reasonably confident in offering this analysis. By the way, the news of the day today has to do with the Senate's backroom bipartisan deal on immigration reform, and I'll certainly post on that once I know more details of the agreement. At first blush, I'm at best greatly conflicted, and I need to reflect for a few days on how this agreement purports to solve such a base failure as our government's failure to adequately secure our nation's borders. But I digress...
With regard to the GOP debate, Mitt Romney was clearly the biggest loser of the night, I think in part because he had done so very well in the previous MSNBC debate. This week Romney was not so sharp, seemed to struggle with some answers, and consequently suffered the letdown of unmet expectations. My impression of Romney from the first debate was that he looked Presidential and in command of the issues. That was not my impression this week.
The conventional wisdom is that Rudy Giuliani helped himself the most among the Big Three with his authoritative focus on national security and his seemingly spontaneous umbrage with Libertarian Ron Paul's blaming of 9/11 in part on American foreign policy. Nevertheless, I do not believe Giuliani can win the GOP nomination with his strategy of embracing his pro-choice views on abortion. I once thought he could possibly finesse the issue with his assurances about appointing strict constructionist judges, but I believe he has needlessly alienated too many social conservatives with what I perceive is a flippancy ("It'd be OK..." to reverse Roe) toward one of the foundational issues of our day. He once had the reserve of good will to handle this issue, but I believe his opportunity is lost.
The debates do not help John McCain. His answers remind me of Al Gore's--the canned responses of an insider. I'm convinced John McCain is pursuing a pipe dream but doesn't know it. He has banked on the tradition of Republicans to nominate "the next in line" (think Bob Dole, George H.W. Bush, even Ronald Reagan in 1980), but he underestimates his negatives. Conservatives remember his campaign finance reform which limits our free speech rights, his opposition to the Bush tax cuts, his coddling of the liberal media in 2000 in part by attacking religious conservatives, and his hamstringing of America's efforts to interrogate terrorists with his publicity-seeking opposition to "torture." McCain is learning the same lesson many other Republicans have learned the hard way--he was once a media darling by virtue of attacking conservatives, but now that the mainstream media has deserted him, he finds himself alienated from those conservatives. His base is now largely comprised of establishment inside-the-Beltway types who have no firm ideology. Support from such folks might normally be enough for a Republican to win the GOP nomination, but I suspect not for McCain, because I think he's made too many conservatives mad.
I've posted before of my support for Mike Huckabee, and I think his polished performances in both GOP debates may be enough to push him up from the mass of lower-tier candidates into his own lone position as a second tier alternative. He clearly had the line of the night with his John Edwards beauty shop one-liner, and his deft handling of questions and fresh yet polished candor is very appealing. National pundits don't appreciate what many of us know--Huckabee's background as a pastor of a large Baptist church is serving him very well right now. Huckabee has also quelled my concern that he might not be committed enough to limited government and lower taxes. He has a proposal for a consumption tax called the "Fair Tax" to replace income and corporate taxes, and his support for this indicates to me that he understands the economic imperative of a limited tax burden. Political consultant Dick Morris has called Huckabee's delivery a combination of Reagan's and Clinton's styles, and after a bit of a shudder at his linkage of these two icons, I can see Morris's point. Huckabee is Reaganesque in his ideology and optimism and his media savvy delivery, but he also emotes and engages the crowd like Clinton can.
We're about two months away from the campaign's second quarter fund-raising reporting, and Huckabee will have to have shown some movement by then if he is to have a chance. I suspect he will. I also predict McCain will muddle along while most media attention is devoted to Giuliani and perhaps a summertime Fred Thompson entry into the race. This is all very interesting to political junkies like me, but it's also critically important for our country as these candidates lay the groundwork for our nation's alternative to the Democratic vision of defeat, retreat, division, and economic and moral decay.
With regard to the GOP debate, Mitt Romney was clearly the biggest loser of the night, I think in part because he had done so very well in the previous MSNBC debate. This week Romney was not so sharp, seemed to struggle with some answers, and consequently suffered the letdown of unmet expectations. My impression of Romney from the first debate was that he looked Presidential and in command of the issues. That was not my impression this week.
The conventional wisdom is that Rudy Giuliani helped himself the most among the Big Three with his authoritative focus on national security and his seemingly spontaneous umbrage with Libertarian Ron Paul's blaming of 9/11 in part on American foreign policy. Nevertheless, I do not believe Giuliani can win the GOP nomination with his strategy of embracing his pro-choice views on abortion. I once thought he could possibly finesse the issue with his assurances about appointing strict constructionist judges, but I believe he has needlessly alienated too many social conservatives with what I perceive is a flippancy ("It'd be OK..." to reverse Roe) toward one of the foundational issues of our day. He once had the reserve of good will to handle this issue, but I believe his opportunity is lost.
The debates do not help John McCain. His answers remind me of Al Gore's--the canned responses of an insider. I'm convinced John McCain is pursuing a pipe dream but doesn't know it. He has banked on the tradition of Republicans to nominate "the next in line" (think Bob Dole, George H.W. Bush, even Ronald Reagan in 1980), but he underestimates his negatives. Conservatives remember his campaign finance reform which limits our free speech rights, his opposition to the Bush tax cuts, his coddling of the liberal media in 2000 in part by attacking religious conservatives, and his hamstringing of America's efforts to interrogate terrorists with his publicity-seeking opposition to "torture." McCain is learning the same lesson many other Republicans have learned the hard way--he was once a media darling by virtue of attacking conservatives, but now that the mainstream media has deserted him, he finds himself alienated from those conservatives. His base is now largely comprised of establishment inside-the-Beltway types who have no firm ideology. Support from such folks might normally be enough for a Republican to win the GOP nomination, but I suspect not for McCain, because I think he's made too many conservatives mad.
I've posted before of my support for Mike Huckabee, and I think his polished performances in both GOP debates may be enough to push him up from the mass of lower-tier candidates into his own lone position as a second tier alternative. He clearly had the line of the night with his John Edwards beauty shop one-liner, and his deft handling of questions and fresh yet polished candor is very appealing. National pundits don't appreciate what many of us know--Huckabee's background as a pastor of a large Baptist church is serving him very well right now. Huckabee has also quelled my concern that he might not be committed enough to limited government and lower taxes. He has a proposal for a consumption tax called the "Fair Tax" to replace income and corporate taxes, and his support for this indicates to me that he understands the economic imperative of a limited tax burden. Political consultant Dick Morris has called Huckabee's delivery a combination of Reagan's and Clinton's styles, and after a bit of a shudder at his linkage of these two icons, I can see Morris's point. Huckabee is Reaganesque in his ideology and optimism and his media savvy delivery, but he also emotes and engages the crowd like Clinton can.
We're about two months away from the campaign's second quarter fund-raising reporting, and Huckabee will have to have shown some movement by then if he is to have a chance. I suspect he will. I also predict McCain will muddle along while most media attention is devoted to Giuliani and perhaps a summertime Fred Thompson entry into the race. This is all very interesting to political junkies like me, but it's also critically important for our country as these candidates lay the groundwork for our nation's alternative to the Democratic vision of defeat, retreat, division, and economic and moral decay.
Sunday, May 13, 2007
Who Will Write Our History?
My children and I traveled to Shiloh National Military Park this weekend for a family getaway and history lesson. It was a wonderful and fun trip for the kids and for me, as I remembered similar trips to Shiloh when I was their age. In a time when so many of the defining elements which shape our culture are not being passed to the next generation, it was a joy for me to be able to build memories with them.
As we wandered the beautiful and meticulously kept grounds of the cemetery, John Henry and Lydia were full of questions. Among them were questions about who was buried there, and which side were the "good guys" fighting on? It is hard to explain to seven year olds the concept of a civil war, with brother fighting against brother. Nor did they ever grasp that everyone buried in the cemetery in individual graves fought for the Union, while the Confederate soldiers were buried by the thousands in huge burial trenches. Indeed, according to family lore, my own great great grandfather is buried in one of those trenches, having himself left behind a seven year old daughter who would grow up to become my great grandmother.
The epiphany hit me while we were wandering in the cemetery. History is written by the victors, so it has always been, and so will it always be. We who live generations later can have little real understanding of the milieu which led these ancestors of ours to make the choices they made. We can study and read and educate ourselves, but the truth remains that in a major conflict such as The War Between the States, where basic philosophies are at odds, the victor conquers more than people or land. He vanquishes the losers' ability to frame the debate. I hasten to add that I do not speak of racial matters here, for there can be no reasoned debate on race in today's America.
I speak, instead, of victory in a society's battle of ideas: The South's belief, for example, that their government was the true inheritor of the principles of the Founding Fathers. That the individual states did have a sovereignty that superseded that of the Union. That many who fought for the South fought not for slavery but to defend their homes from what they viewed as armed invaders. Yet none of these truths, as Southerners saw them, has survived to the national identity of today, because the South lost the war. The United States after the Civil War was a very different country from the looser organization of states that existed before the war, and the Southern cultural perspective is now relegated to a quaint footnote, or worse.
My point is not to comment on the consequence of the Civil War on today's America, but rather is to recognize that our society's views are a product of those battles of ideas that have preceded us. Further, we as a people are engaged today in a multitude of battles whose outcome will determine what kind of world our children and our children's children will live in. The victor will tell the story. If you are apathetic about these battles, you shouldn't be. The stakes are high.
We face, among numerous other challenges, an implacable Islamic terrorist foe who believes that women are second class citizens, who denies freedom of speech and religion, and who does not share the traditional Judeo-Christian view of the worth of the individual. If we as a society do not steel ourselves to recognize and fight this enemy, it is hardly an exaggeration to believe that our progeny might grow up under sharia law, with no understanding or appreciation for the freedoms we now take for granted. It does not matter whether we acknowledge the threat we face---the threat is before us and threatens our very existence. We ignore it at our children's peril.
Scripture tells us in the Book of Judges that the Hebrew people did such a poor job of teaching their children that, " ... a generation grew up which knew neither the Lord nor the things He had done for Israel." (Judges 2:10) It is incredible that after all God had done for the Hebrews--delivering them from Pharoah and slavery, parting the Red Sea, delivering The Ten Commandments, parting the Jordan River, and delivering Jericho--that God's people did not teach their children about Him. Let us not make the mistake that those Hebrews made. Let us recognize and engage our foes, and teach our children to appreciate and defend the blessings of Western civilization, so that they can carry those blessings forward for themselves and our children's children.
As we wandered the beautiful and meticulously kept grounds of the cemetery, John Henry and Lydia were full of questions. Among them were questions about who was buried there, and which side were the "good guys" fighting on? It is hard to explain to seven year olds the concept of a civil war, with brother fighting against brother. Nor did they ever grasp that everyone buried in the cemetery in individual graves fought for the Union, while the Confederate soldiers were buried by the thousands in huge burial trenches. Indeed, according to family lore, my own great great grandfather is buried in one of those trenches, having himself left behind a seven year old daughter who would grow up to become my great grandmother.
The epiphany hit me while we were wandering in the cemetery. History is written by the victors, so it has always been, and so will it always be. We who live generations later can have little real understanding of the milieu which led these ancestors of ours to make the choices they made. We can study and read and educate ourselves, but the truth remains that in a major conflict such as The War Between the States, where basic philosophies are at odds, the victor conquers more than people or land. He vanquishes the losers' ability to frame the debate. I hasten to add that I do not speak of racial matters here, for there can be no reasoned debate on race in today's America.
I speak, instead, of victory in a society's battle of ideas: The South's belief, for example, that their government was the true inheritor of the principles of the Founding Fathers. That the individual states did have a sovereignty that superseded that of the Union. That many who fought for the South fought not for slavery but to defend their homes from what they viewed as armed invaders. Yet none of these truths, as Southerners saw them, has survived to the national identity of today, because the South lost the war. The United States after the Civil War was a very different country from the looser organization of states that existed before the war, and the Southern cultural perspective is now relegated to a quaint footnote, or worse.
My point is not to comment on the consequence of the Civil War on today's America, but rather is to recognize that our society's views are a product of those battles of ideas that have preceded us. Further, we as a people are engaged today in a multitude of battles whose outcome will determine what kind of world our children and our children's children will live in. The victor will tell the story. If you are apathetic about these battles, you shouldn't be. The stakes are high.
We face, among numerous other challenges, an implacable Islamic terrorist foe who believes that women are second class citizens, who denies freedom of speech and religion, and who does not share the traditional Judeo-Christian view of the worth of the individual. If we as a society do not steel ourselves to recognize and fight this enemy, it is hardly an exaggeration to believe that our progeny might grow up under sharia law, with no understanding or appreciation for the freedoms we now take for granted. It does not matter whether we acknowledge the threat we face---the threat is before us and threatens our very existence. We ignore it at our children's peril.
Scripture tells us in the Book of Judges that the Hebrew people did such a poor job of teaching their children that, " ... a generation grew up which knew neither the Lord nor the things He had done for Israel." (Judges 2:10) It is incredible that after all God had done for the Hebrews--delivering them from Pharoah and slavery, parting the Red Sea, delivering The Ten Commandments, parting the Jordan River, and delivering Jericho--that God's people did not teach their children about Him. Let us not make the mistake that those Hebrews made. Let us recognize and engage our foes, and teach our children to appreciate and defend the blessings of Western civilization, so that they can carry those blessings forward for themselves and our children's children.
Sunday, April 29, 2007
America's Reputation
I read a recent quote from John McCain that one of his first tasks, should he be elected President, would be to "restore" America's reputation in the world. Implicit in his statement is the criticism that George W. Bush has harmed America's stature in the world, and that it is a priority that other nations "like" us. I've been fuming ever since I read the quote, but it fits well with other McCain policy positions over the past couple of years. It was McCain who forced President Bush to tie the hands of American military investigators by publicizing which techniques are acceptable for interrogation of military prisoners. I remember then that McCain said we needed to "show the world" that we are different.
I beg to differ. The worldview of those who hate America will not be changed one iota no matter what we do, and the empirical evidence of the superiority of the American way is manifestly obvious to anyone who cares to see. I do not understand this need of American appeasers to be liked. It certainly should not be a matter of national priority. We must however, be respected, and the resolve of our national will should be unquestioned. The lesson Osama bin Laden learned from the American response to Somalia, to the U.S.S. Cole and West African embassy bombings, and other attacks on American interests over the years, was that America would cut its losses and sell out its allies when pushed to the brink. We were viewed as impotent and weak and unwilling to stay a difficult course. Say what you will, and notwithstanding his mistakes, God bless George W. Bush for proving Osama wrong and for showing the world that our resolve is strong, at least for the last six years.
The goodness of America is seen in the millions who want to come here to start new lives, and in the strength and resiliency of our economy. The foreigners who hate America are motivated by interests which are contrary to American interests, and examples include Russia, China, North Korea, and of course the Islamist states. Left-wing European elites oppose America partly from jealousy and partly to further their own economic interests in competition with America's. Can anyone be so gullible as to be deceived by these people? Unfortunately, yes. That the Democrats and some Republicans running for President do not see this obvious truth reflects, I think, an insular mindset that often develops among those who are too comfortable with power and its trappings.
I myself am not fully comfortable with the degree of the Bush policy of intervention and engagement in the world, and I do see problems related, for instance, to American national security from unbridled free trade policy, but the arguments of the Left against such policies are breathtakingly shallow and hypocritical, and I am almost ashamed for the people making them. However, it is in the context of today's Republican party that real ideas are being debated with intellectual rigor, vigor, and respect. Such debates over immigration, trade policy, and education reform are driven intellectually from the Right, and whatever policy coalesces from these debates will be stronger and better because it will have been borne from this crucible of moral and intellectual discourse.
I've written above of my unhappiness with John McCain's policies (while I honor his unquestionably heroic service to our country), and I have grave concerns at this point about each of the top tier GOP Presidential candidates. I've also written about Mike Huckabee, and I really believe that if he could just get a little more exposure, others would find him as appealing as I do. Huckabee did win a recent straw poll among GOP activists in Spartanburg, South Carolina, and I'm hopeful that this portends a move up for him in South Carolina, which is a critical early primary state.
America is the greatest nation the world has ever known, albeit with flaws, but unquestionably great. I am sorry that some who have inherited bountifully from her greatness are so quick to carry water for her enemies, and I pray that come November 2008 we have at least one choice for President who can stand tall for America's interests.
I beg to differ. The worldview of those who hate America will not be changed one iota no matter what we do, and the empirical evidence of the superiority of the American way is manifestly obvious to anyone who cares to see. I do not understand this need of American appeasers to be liked. It certainly should not be a matter of national priority. We must however, be respected, and the resolve of our national will should be unquestioned. The lesson Osama bin Laden learned from the American response to Somalia, to the U.S.S. Cole and West African embassy bombings, and other attacks on American interests over the years, was that America would cut its losses and sell out its allies when pushed to the brink. We were viewed as impotent and weak and unwilling to stay a difficult course. Say what you will, and notwithstanding his mistakes, God bless George W. Bush for proving Osama wrong and for showing the world that our resolve is strong, at least for the last six years.
The goodness of America is seen in the millions who want to come here to start new lives, and in the strength and resiliency of our economy. The foreigners who hate America are motivated by interests which are contrary to American interests, and examples include Russia, China, North Korea, and of course the Islamist states. Left-wing European elites oppose America partly from jealousy and partly to further their own economic interests in competition with America's. Can anyone be so gullible as to be deceived by these people? Unfortunately, yes. That the Democrats and some Republicans running for President do not see this obvious truth reflects, I think, an insular mindset that often develops among those who are too comfortable with power and its trappings.
I myself am not fully comfortable with the degree of the Bush policy of intervention and engagement in the world, and I do see problems related, for instance, to American national security from unbridled free trade policy, but the arguments of the Left against such policies are breathtakingly shallow and hypocritical, and I am almost ashamed for the people making them. However, it is in the context of today's Republican party that real ideas are being debated with intellectual rigor, vigor, and respect. Such debates over immigration, trade policy, and education reform are driven intellectually from the Right, and whatever policy coalesces from these debates will be stronger and better because it will have been borne from this crucible of moral and intellectual discourse.
I've written above of my unhappiness with John McCain's policies (while I honor his unquestionably heroic service to our country), and I have grave concerns at this point about each of the top tier GOP Presidential candidates. I've also written about Mike Huckabee, and I really believe that if he could just get a little more exposure, others would find him as appealing as I do. Huckabee did win a recent straw poll among GOP activists in Spartanburg, South Carolina, and I'm hopeful that this portends a move up for him in South Carolina, which is a critical early primary state.
America is the greatest nation the world has ever known, albeit with flaws, but unquestionably great. I am sorry that some who have inherited bountifully from her greatness are so quick to carry water for her enemies, and I pray that come November 2008 we have at least one choice for President who can stand tall for America's interests.
Sunday, April 22, 2007
Health Care--Who Controls Your Choices?
Who makes your health care choices--you, your doctor, your insurance plan, or your government? Who should make such choices, and who should pay for the delivery of the chosen services? In truth, each of the four entities I mentioned above plays some role in the delivery of health care in America. Today marks my first effort at discussing the state of health care delivery in the United States, and it's my opinion that the critical question is the one I asked at the beginning of this paragraph. Who should be paying for the array of wonderful and advanced treatments available to us?
Our society has come to accept the notion of health care as a "right," and that it should be available, at least at a basic level, for everyone regardless of their ability to pay. This principle collides, however, with the inconvenient truth that someone must pay. As a provider, I wouldn't be in business very long if I did not pay my staff and my office rent and insurance and all the other expenses associated with a medical practice, not to mention that I would like to provide for my family. The tension evident in today's system results from the fact that the users of a given service, poor or not, are largely removed from directly paying for that service. This divergence drives up the costs of care and the demand for services.
For the vast middle class in America, the linkage between a health care service and its cost is lost, and the result is greater demand at greater cost, and ultimately more limited choices. The schism that I'm talking about has come about because of the huge and intrusive role of third-party payors--insurance companies and government--that has developed over the years. I can give a multitude of examples, but I'll be brief to try to illustrate my points. For every service or good you can think of, there is a balance between supply and demand, and cost is the expression of that balance. Assuming you're not on food stamps, who pays for your groceries? You do, of course, as you do your phone bill and your car payment and whatever else you buy. Now, again assuming you are part of America's great middle class, how did you choose which car you drive? The answer is that you bought the car you wanted, that fit your needs, and that you could afford. No one expects to pay their employer or the government a monthly premium, and to be given a choice of three different cars to pick from every March. And if my absurd illustration were true, I'll assure you that not only would your car choice be limited, it would be more expensive, as well. Competition is a potent motivator, and innovation is its result.
Apart from emergency care, my illustration above is as equally applicable to health care services as it is to car purchases or haircuts or groceries. Unless our current system changes, patients will in the future have vastly greater restrictions placed on them with regard to choice of doctors, hospitals, treatments, and medicines. We are already seeing examples in physician provider panels, and in medicine formularies that pay for only one drug, if any, in a given class. The bureaucracy chooses which medicine to pay for, and which physicians to contract with, and those choices are driven by interests that are often at odds with the patient's best interests. Physicians, for their part, have little incentive to openly publish their fees or compete for patients based on convenience issues such as flexible appointment availability or timely message return. Employers, saddled with the job of picking insurance options for their employees, are left with a responsibility and cost they'd rather not have, but which has developed because of a longstanding tax loophole which favors employer-provided health insurance. Human nature can't be legislated, and those who pay the bills will always control the process. My fear is that the precious doctor-patient relationship is at risk from these outside forces.
One ridiculous and disingenuous proposal before Congress now is to have the federal government "negotiate" drug prices with pharmaceutical companies. This means price controls, and I can't think of a more effective way to dry up the basic research that leads to breakthrough treatments, which now routinely cost one billion dollars or more to bring a single drug to market. Certainly it's not fair that we are the only major Western nation without price controls, and the result is that we wind up subsidizing new drug development for these socialized countries. But the solution is not to do wrong just because everyone else is. I am armed today with a potent arsenal of drugs which are effective treatments for hypertension, diabetes, and heart disease, and many of these drugs did not exist 13 years ago when I entered private practice. Lives are being saved today because of the existence of these medicines. Instead of beating up on Big Pharma, lots of folks need to give them a word of thanks, and we should let our congressmen know how we feel, as well.
Nobody wants to hear doctors poor-mouth about money, but the truth is that primary care physician incomes are down about 9% in inflation-adjusted dollars over the last 10 years, and Medicare reimbursements are on track to be reduced even more drastically in years to come. Let's say you're a doctor with a full practice, and Medicare reimburses you only about 60% of what a private insurance plan would for the same service. How anxious would you be to fill all your slots with Medicare patients? Not very, and therein lies a substantial looming problem for everyone nearing the age of 65. Reimbursement is better with private insurance than with Medicare, but the same issues are in play, just delayed a little bit.
I'm a board-certified internal medicine specialist, and I deliver what I believe to be excellent care for my patients. Yet, I'm only a participant in three of the four available Blue Cross plans in the area, for example. Why am I not part of the fourth? It has nothing to do with my qualifications, but is because I was unwilling to provide my services at the price Blue Cross offered for that particular insurance plan. Meanwhile, I provide exactly the same services for Blue Cross patients in the other three plans, for a fee that I find acceptable. Blue Cross, and employers, you see, are driven by different motivations than patients themselves might be. Why should the employer or the insuror determine whether a patient can see me? I submit that the cost, quality, and choice available to patients would be greatly improved if the patients were more directly responsible for the cost of their care.
How might this be accomplished? One solution is being implemented now in the form of high-deductible health insurance plans coupled with health savings accounts. These programs are relatively new but are already transforming the health care delivery dynamic. The problem is that these plans are not nearly available enough to make a dent in the overall system. If these plans were more widely used, patients would likely become much more savvy consumers of health care dollars, and doctors would ultimately be forced to compete for patients much more directly in terms of transparency of cost, availability and convenience of services, and patient satisfaction indices. In my own new solo practice, I'm trying to implement some of these protocols, but in many ways I'm swimming upstream with my efforts. In any case, it's not just my solution, or anyone else's solution, but a multitude of solutions that will fit the needs of a diverse America. This is the vision I have for health care in America, with the patients and their doctors driving innovation.
Sure, patients may not immediately see the problems with third-party payors as I see them, and indeed these problems have developed gradually over the last 50 years. Nevertheless, the predicament is real and worsening, and I pray for wise leadership to bring us to sustainable long-term solutions. The surest path to success will be one in which the individual patient maintains maximal control over his own health care decisions, and that recognizes that it is the payor who has the control. I've chosen to be a solo practitioner for the freedom and flexibility that are its fruit, both for me and for my patients. I believe that people will value what I have to offer. On a broader scale, I hope Americans will continue to have a rich array of health care options in future years. It's not a given that we will.
Our society has come to accept the notion of health care as a "right," and that it should be available, at least at a basic level, for everyone regardless of their ability to pay. This principle collides, however, with the inconvenient truth that someone must pay. As a provider, I wouldn't be in business very long if I did not pay my staff and my office rent and insurance and all the other expenses associated with a medical practice, not to mention that I would like to provide for my family. The tension evident in today's system results from the fact that the users of a given service, poor or not, are largely removed from directly paying for that service. This divergence drives up the costs of care and the demand for services.
For the vast middle class in America, the linkage between a health care service and its cost is lost, and the result is greater demand at greater cost, and ultimately more limited choices. The schism that I'm talking about has come about because of the huge and intrusive role of third-party payors--insurance companies and government--that has developed over the years. I can give a multitude of examples, but I'll be brief to try to illustrate my points. For every service or good you can think of, there is a balance between supply and demand, and cost is the expression of that balance. Assuming you're not on food stamps, who pays for your groceries? You do, of course, as you do your phone bill and your car payment and whatever else you buy. Now, again assuming you are part of America's great middle class, how did you choose which car you drive? The answer is that you bought the car you wanted, that fit your needs, and that you could afford. No one expects to pay their employer or the government a monthly premium, and to be given a choice of three different cars to pick from every March. And if my absurd illustration were true, I'll assure you that not only would your car choice be limited, it would be more expensive, as well. Competition is a potent motivator, and innovation is its result.
Apart from emergency care, my illustration above is as equally applicable to health care services as it is to car purchases or haircuts or groceries. Unless our current system changes, patients will in the future have vastly greater restrictions placed on them with regard to choice of doctors, hospitals, treatments, and medicines. We are already seeing examples in physician provider panels, and in medicine formularies that pay for only one drug, if any, in a given class. The bureaucracy chooses which medicine to pay for, and which physicians to contract with, and those choices are driven by interests that are often at odds with the patient's best interests. Physicians, for their part, have little incentive to openly publish their fees or compete for patients based on convenience issues such as flexible appointment availability or timely message return. Employers, saddled with the job of picking insurance options for their employees, are left with a responsibility and cost they'd rather not have, but which has developed because of a longstanding tax loophole which favors employer-provided health insurance. Human nature can't be legislated, and those who pay the bills will always control the process. My fear is that the precious doctor-patient relationship is at risk from these outside forces.
One ridiculous and disingenuous proposal before Congress now is to have the federal government "negotiate" drug prices with pharmaceutical companies. This means price controls, and I can't think of a more effective way to dry up the basic research that leads to breakthrough treatments, which now routinely cost one billion dollars or more to bring a single drug to market. Certainly it's not fair that we are the only major Western nation without price controls, and the result is that we wind up subsidizing new drug development for these socialized countries. But the solution is not to do wrong just because everyone else is. I am armed today with a potent arsenal of drugs which are effective treatments for hypertension, diabetes, and heart disease, and many of these drugs did not exist 13 years ago when I entered private practice. Lives are being saved today because of the existence of these medicines. Instead of beating up on Big Pharma, lots of folks need to give them a word of thanks, and we should let our congressmen know how we feel, as well.
Nobody wants to hear doctors poor-mouth about money, but the truth is that primary care physician incomes are down about 9% in inflation-adjusted dollars over the last 10 years, and Medicare reimbursements are on track to be reduced even more drastically in years to come. Let's say you're a doctor with a full practice, and Medicare reimburses you only about 60% of what a private insurance plan would for the same service. How anxious would you be to fill all your slots with Medicare patients? Not very, and therein lies a substantial looming problem for everyone nearing the age of 65. Reimbursement is better with private insurance than with Medicare, but the same issues are in play, just delayed a little bit.
I'm a board-certified internal medicine specialist, and I deliver what I believe to be excellent care for my patients. Yet, I'm only a participant in three of the four available Blue Cross plans in the area, for example. Why am I not part of the fourth? It has nothing to do with my qualifications, but is because I was unwilling to provide my services at the price Blue Cross offered for that particular insurance plan. Meanwhile, I provide exactly the same services for Blue Cross patients in the other three plans, for a fee that I find acceptable. Blue Cross, and employers, you see, are driven by different motivations than patients themselves might be. Why should the employer or the insuror determine whether a patient can see me? I submit that the cost, quality, and choice available to patients would be greatly improved if the patients were more directly responsible for the cost of their care.
How might this be accomplished? One solution is being implemented now in the form of high-deductible health insurance plans coupled with health savings accounts. These programs are relatively new but are already transforming the health care delivery dynamic. The problem is that these plans are not nearly available enough to make a dent in the overall system. If these plans were more widely used, patients would likely become much more savvy consumers of health care dollars, and doctors would ultimately be forced to compete for patients much more directly in terms of transparency of cost, availability and convenience of services, and patient satisfaction indices. In my own new solo practice, I'm trying to implement some of these protocols, but in many ways I'm swimming upstream with my efforts. In any case, it's not just my solution, or anyone else's solution, but a multitude of solutions that will fit the needs of a diverse America. This is the vision I have for health care in America, with the patients and their doctors driving innovation.
Sure, patients may not immediately see the problems with third-party payors as I see them, and indeed these problems have developed gradually over the last 50 years. Nevertheless, the predicament is real and worsening, and I pray for wise leadership to bring us to sustainable long-term solutions. The surest path to success will be one in which the individual patient maintains maximal control over his own health care decisions, and that recognizes that it is the payor who has the control. I've chosen to be a solo practitioner for the freedom and flexibility that are its fruit, both for me and for my patients. I believe that people will value what I have to offer. On a broader scale, I hope Americans will continue to have a rich array of health care options in future years. It's not a given that we will.
Wednesday, April 18, 2007
A Crucial Victory, By A Hair
Today's Supreme Court decision backing limits on partial birth abortion represents the first fruits of the Bush judicial realignment, and marks a watershed moment in the battle for recognition of the rights of the unborn. With a vote of 5 to 4, the decision also illustrates the tenuous and precarious character of the hard-won battles over conservative judicial nominees. Make no mistake, the liberal Left recognizes the stakes, and today's result reinforces their strategy of delay, delay, and delay, in hopes that President Bush will tire of the fight, and that he will be replaced by a Democrat. No issue personifies the distinction between the two national parties more than that of abortion, and the evidence of that can be seen in the responses of the candidates of the two parties for the Presidential nomination. To a man, the Republican candidates were supportive of the decision, even Giuliani, who is no friend of the pro-life movement. Conversely, every Democratic contender was critical of the decision. The amalgamation of interest groups that is the national Democratic party has no unifying philosophy, apart from Bush hatred, unless it is the absolute right of a woman to abort her baby, down to the very last birth contraction, or even beyond. That today's victory has been so long in coming speaks to the success of the abortion industry's tactics, yet even so our focus today should be one of exultation in the sweet aroma of long-awaited judicial victory.
The ruling marks the first restriction on abortion that has passed constitutional muster since Roe (apart from those with exceptions for "health of the mother," which are deceptive smokescreens emasculating the intent of the restrictions). Today's decision has no such exception, and is therefore landmark in its scope. It seems likely to me that future Roberts Court decisions on abortion will focus on building a constitutional bulwark of judgments that gives legitimacy to abortion restrictions, and I think it is unlikely that the votes will exist on the Supreme Court in the foreseeable future to flatly overturn the travesty that is Roe v. Wade. Given the politics and the personalities of the players involved, I suspect Chief Justice Roberts has wisely opted to aim for base hits, to use a baseball metaphor, rather than shooting for the fence with a home run overturning Roe. I believe Roberts has chosen the wiser course, and one that will most likely yield long term success for the pro-life movement.
While we must always remember that our ultimate purpose is to honor and protect the lives of unborn babies, today's ruling also has a secondary and very interesting side benefit. Occurring as it has in the hotbed of Presidential primary politicking, the decision has focused attention on the nuances of the various Republican candidates' abortion rights stances. The decision does not have the same tactical implications for Democratic candidates since their positions are all in lockstep with Planned Parenthood and NARAL. For the Republicans, however, obfuscation and deflection will be more difficult as a result of the new legal landscape, and greater clarity in their positions will be required. This is certainly to our benefit as voters.
I await with interest how all today's events shake out with Republican primary voters. I've previously posted my opinion that none of the top tier GOP candidates have completely sound pro-life credentials, and I hope one result of the renewed focus on abortion will be to cement the pro-life platform of whoever is the Republican nominee. While I can respect Giuliani for at least his consistency regarding his position on abortion rights, I'm convinced both McCain and Romney will perform whatever contortions are necessary to win the Presidency, and that the pro-life worldview is not foundational for them. Meanwhile, I'm amazed at the descriptions I've read of Fred Thompson's pro-life record. I do understand the attractiveness of, and could even support, a Fred Thompson candidacy, but he is most assuredly not a bedrock pro-life partisan.
Fred is, however, a states' rights federalist, and it is on that basis that I could support him. I believe he would indeed appoint strict judicial constructionists to the federal bench, and the end result for pro-lifers would be the same, since Roe is itself such a perversion of constitutional law. I believe Fred would justify his position, not on principles of Divinely-authored respect for life, but instead on the improper usurpation by the courts of an issue more properly decided in the political arena. Either argument is intellectually sound and achieves the same goal.
Notwithstanding all of the above, President Bush has been correct in saying that the larger task for pro-lifers is to engage with mainstream America to promote a "culture of life." Without success in that arena we will never achieve the political victory that we are seeking. Let us busy ourselves about that task as we savor today's nugget of triumph.
The ruling marks the first restriction on abortion that has passed constitutional muster since Roe (apart from those with exceptions for "health of the mother," which are deceptive smokescreens emasculating the intent of the restrictions). Today's decision has no such exception, and is therefore landmark in its scope. It seems likely to me that future Roberts Court decisions on abortion will focus on building a constitutional bulwark of judgments that gives legitimacy to abortion restrictions, and I think it is unlikely that the votes will exist on the Supreme Court in the foreseeable future to flatly overturn the travesty that is Roe v. Wade. Given the politics and the personalities of the players involved, I suspect Chief Justice Roberts has wisely opted to aim for base hits, to use a baseball metaphor, rather than shooting for the fence with a home run overturning Roe. I believe Roberts has chosen the wiser course, and one that will most likely yield long term success for the pro-life movement.
While we must always remember that our ultimate purpose is to honor and protect the lives of unborn babies, today's ruling also has a secondary and very interesting side benefit. Occurring as it has in the hotbed of Presidential primary politicking, the decision has focused attention on the nuances of the various Republican candidates' abortion rights stances. The decision does not have the same tactical implications for Democratic candidates since their positions are all in lockstep with Planned Parenthood and NARAL. For the Republicans, however, obfuscation and deflection will be more difficult as a result of the new legal landscape, and greater clarity in their positions will be required. This is certainly to our benefit as voters.
I await with interest how all today's events shake out with Republican primary voters. I've previously posted my opinion that none of the top tier GOP candidates have completely sound pro-life credentials, and I hope one result of the renewed focus on abortion will be to cement the pro-life platform of whoever is the Republican nominee. While I can respect Giuliani for at least his consistency regarding his position on abortion rights, I'm convinced both McCain and Romney will perform whatever contortions are necessary to win the Presidency, and that the pro-life worldview is not foundational for them. Meanwhile, I'm amazed at the descriptions I've read of Fred Thompson's pro-life record. I do understand the attractiveness of, and could even support, a Fred Thompson candidacy, but he is most assuredly not a bedrock pro-life partisan.
Fred is, however, a states' rights federalist, and it is on that basis that I could support him. I believe he would indeed appoint strict judicial constructionists to the federal bench, and the end result for pro-lifers would be the same, since Roe is itself such a perversion of constitutional law. I believe Fred would justify his position, not on principles of Divinely-authored respect for life, but instead on the improper usurpation by the courts of an issue more properly decided in the political arena. Either argument is intellectually sound and achieves the same goal.
Notwithstanding all of the above, President Bush has been correct in saying that the larger task for pro-lifers is to engage with mainstream America to promote a "culture of life." Without success in that arena we will never achieve the political victory that we are seeking. Let us busy ourselves about that task as we savor today's nugget of triumph.
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