Friday, February 27, 2009

Why Health Care Jobs Are Not Safe

Just recently, someone commented to me how fortunate I was to work in health care. They believed that a job in our industry must be lucrative and secure with excellent benefits – somehow untouched by the collapse of the financial industry specifically, and the economy as a whole. “You'll always have work. People will always need medical care”, was what they told me.

I was quick to point out that while health care may be necessary, it is not always funded. Hospitals in the U.S. operate in an environment where we cannot turn people away for emergent care regardless of a patient's ability to pay. Because people who lack insurance also usually lack a primary care physician they can call and see, they come to the ER. Remember when Bush told us that America had the best health care in the world and all people had to do to access it was go the ER? Well, that was his big plan for health care. Kind of like the Nike ad - “just do it” - people were just supposed to go the ER for whatever they needed. Of course, no one pays for care given to people without insurance. There is little we can do other than to write off the care as a loss.

Over the past several decades, insurance companies have been collecting higher and higher premiums from policy holders and actively working to pay out less and less in reimbursements for care given. They are for profit agencies and they are doing what our system allows them to do. But over the years, as health care sees and treats more and more people, and people expect more and more care and insurers pay less and less, we have been left with fiscal instability.

Adding to this imbalance is the current budget shortfalls of most states – the suppliers of the Medicaid programs. With states having less money available to fund their Medicaid programs, reimbursements have dropped. In some states, like Maine, the state owes hundreds of millions of dollars to hospitals over the past several years that have yet to be paid.

What makes me most concerned at the moment however, is the current state of the insurance companies. Without a funded national health care plan in place – that means actually funded, not just some numbers on paper – we are at the mercy of insurers. When they can't pay for medical care, we are all in trouble.

We have all heard about banks and financial companies and the troubles they are having, but much less discussed is the sad state of most insurance companies. Banks have been in the news for huge losses, but insurers have managed to slip by unnoticed as their losses, less impressive in size, have been as consistent over the past two years.

Check out a few stock charts on some of the largest insurers over the past 2 years. Below are charts on Cigna, Aetna, Humana and UnitedHealth.

Now, it might just be me, but I think there is a definite trend here. Notice the sharp downward turn each large company has taken over the last 2 years. That translates to less reserves on hand, bad investments, credit default swap exposure, and poor choices by management. The only reason the insurers have not been in the forefront of this disaster is because the banks have been so much more impressive in their losses. But not for long.

When the insurance companies start to fail, they will be unable to pay for health care provided for policy holders. The government will be forced to step up and fill the void. Of course, they could just try and bail them out (like they have already begun to do with AIG), but it would make much more sense at that point to just nationalize health care and be done with it. Like their larger siblings the banks, insurers will require support at unprecedented levels if they are to remain solvent - but that may not be the best plan.

What all this means for heath care workers is this: without a revenue stream to pay for care, we are all at risk until someone admits the current system is unsustainable and decides to rebuild it from the ground up, removing private insurers as the main source of reimbursement. How that should be done is another topic for another day.

Wednesday, February 25, 2009

Savings, Savings, Savings

I did not see Obama's speech last night – I was too tired to watch it after a couple of long days at work and little sleep. I did read the text this morning in the NYT and was mostly satisfied with what I read. The tone is upbeat (more honest than we have been used to over the past 8 years) and there are good things in what he proposes. But the one thing I did not read was any acknowledgement that Americans have been and still are addicted to debt.

I read it was important to start lending again. I read that banks and regulators were going to be accountable. I read that we needed to be able to finance that college education or new car. What I didn't read was that we need to stop borrowing so much and saving so little.

Why is that still some sort of taboo topic? Why is it not OK to say to the American populace, “hey, stupid – don't have three credit cards with balances that are larger than your annual income”? Why is it not OK to tell people that not everyone can AFFORD a new BMW or a McMansion? I'll accept that many credit card offers in the mail seem just too good to pass up, and that all that credit is tempting – but come on! Like Chris Rock has noted - “Just because you can drive a car with your feet don't make it a good idea”.

In 2002 the San Francisco Fed reported in a letter regarding savings rates:

“From 1980 through 1994, the U.S. saving rate averaged 8%; thereafter, it fell steeply, and since mid-2000, with allowance made for the tax rebates that boosted household saving in the months of July, August, and September 2001, it has averaged approximately 1%. By contrast, the personal saving rates from 1980 through 2001 averaged 13% in Japan, 12% in Germany, and 15% in France, with no steep declines after 1994; in fact, in France, the saving rate rose slightly. For the United Kingdom, the personal saving rate was close to the U.S. rate during the 1980 to 1994 period, averaging 9%, but it has since declined only modestly to an average of 7% after 1994, while exhibiting very large swings throughout the sample period. For Canada, the personal saving rate did decline sharply during the latter half of the 1990s, but it is still higher than the U.S. rates, averaging 16% from 1980 through 1994 and 7% since 1994.”

And that was before we actually went negative in 2005. Today, we are moving back into positive territory and as of the end of 2008, we are just below 3%. But we still have a long way to go to get to where most other G20 nations are, and to add to our problems, we carry more household debt than anyone.

Just getting credit thawed won't get the economy running again. First, we need people worthy of getting loans to apply. Most people who don't absolutely need money today are not borrowing, so who's going to be looking for a loan? Oh, that's right - people who are high risk. Just what we need - more bad debt. Is anyone else seeing an issue here?

Now, I do agree that there was and (still is) predatory lending, confusing paperwork and too many other bad practices out there for the banks not to be blamed for a good part of this mess. And we encouraged people to borrow more and more without consideration for tomorrow - just like our government does. But Americans should have understood that all their debt was going to be a problem at some point - yet we ignored common sense for euphoria over a new plasma TV (to watch bad shows, no less).

The other thing we need to do is to stop believing that adding money into our retirement accounts is going to get us anywhere. People, those funds are invested. That's another reason why we are broke. We put no cash into an account at the local bank, but "save" significant amounts into retirement (which goes right into the stock market) and thus we find ourselves with no cash on hand AND smaller retirement savings than we planned on. I have stopped the retirement garbage. It's my money - I worked hard for it - I will take care of it, thank-you.

To read Obama's speech, you could be forgiven for thinking that we just need to free up credit lines so we can borrow again. But is the problem really that we can't borrow – or is it that we have already borrowed too much? I'm happy that the bankers and the regulators are going to get scolded for their role in all of this, but I think Americans need to be taken to task as well for being so greedy and short sighted.

Some times you just have to take a good, long, hard look in the mirror to see your problem.

Sunday, February 22, 2009

What ever happened to personal accountability?

Some days even my jaw can hit the floor.

Recently, a patient came into our ER with a request to be evaluated after surgery. This struck me as odd since surgical patients are expected to follow up with their surgeon after they are discharged. They normally are given instructions for home care and an appointment to meet with the surgeon in the next 1-2 weeks. This patient explained that he was not going to be following up with his surgeon because he had moved. Not the surgeon - but the patient. And on the day of his discharge from the hospital no less. The patient then further offered that he had moved to our state from one over a thousand miles away.

The patient had surgical drains still in place and wounds that were still fresh. When asked why he decided to move to our state, he replied that his cousin lived here and told him how good our state Medicaid program was and that it would be easy to move here and collect disability so he would not have to work. Since the patient was relatively young and untethered to a family, he decided to come north and try and make a go of it (on the state's dime).

I'm not sure what was worse – the fact that the patient thought this was a good plan, or the fact that he was willing to share it with people.

The patient, not surprisingly, was dumbfounded when we asked if he had told any of his physicians about his decision to move. He also seemed more than a bit confused when asked if he had contacted any providers here to follow up with him and his on going medical problems and needs as time went forward. A simple “no” was all that was provided in response.

The patient has complicated medical problems that will be expensive to address and will likely not improve. His complete lack of understanding about what medicine can and cannot do for him is not much of a surprise, as many people struggle with this, but his absolute disconnect from responsibility was amazingly irritating. This patient, through his own personal choices, had managed to severely damage his body to the point that his life expectancy is likely less than 5 years. But he wants us (that's a collective us, as in the American public) to take care of him. That, he feels, is his right - to be taken care of despite his egocentric behavior and without delay (hence the move to Maine).

It was not clear to me when exactly this patient had resigned his position within the banking industry. He was a young man, and so he must have moved up the ranks in a quick fashion. Interestingly enough, he left his previous state on a bus instead of his private jet. He must have left it behind so it would be easier to make his case for disability and Medicaid. A trick he learned, no doubt, by watching the auto industry executives on their second trip to Washington to beg for aid.

What has become of us? If this is the mentality that is prevalent throughout all socioeconomic levels in our country, we are in more trouble than I have feared. When the poor, the middle class and the wealthy all feel like they are victims and deserve to be made whole again by the rest of society, despite any and all evidence that their situation has been self-inflicted, then perhaps it is time for a serious discussion about the permanence of consequences.

Bank executives who watched and encouraged their loan officers to give large sums of money to people who should have had a hard time borrowing cab fare; home buyers who thought they should be able to afford a $750,000 home on a $50,000 salary; investors who bought real estate at over inflated prices thinking the value could only ever rise; alcoholic drug abusers who trash their liver and pancreas before they reach 40 because the only thing that mattered was the “high” - all these people have the same disease. None of them have the ability to take responsibility for their actions and live with the consequences. They represent the worst in us as a society.

I think I may just take a page out of the Alcoholics Anonymous book and start my own support group for people who feel entitled to everything at everyone else's expense. I can see it now – a poorly lit church basement with bad coffee brewing and white styrofoam cups on the folding table. A man stands and walks to the front of the group to address them:

Speaker - “Hi everyone. My name is Ted.”

Group - “Hi Ted.”

Speaker - “I'm a greedy and irresponsible American.”

Group - “Suck it up Ted! And that coffee's not free you know.......”

Thursday, February 19, 2009

Just Who Has Influence Anyway?

In all this financial debacle it has become ever more clear to me that the U.S. Government, the same one Lincoln referred to as a government “of the people, by the people and for the people” is now more accurately described as one “of the corrupt, for the the corrupt and by the corrupt”. The notion of a government that is representative of its citizens is passe and has been replaced by the practice of government for the highest bidder. The role of lobbying (long established and practiced in the U.S.) has grown to ridiculous proportions in today's world.

The latest numbers on lobbying are available at Their research shows that in 2008, 15,150 registered lobbyists were working for various industries trying to influence policy. That's more than 28 lobbyists per member of Congress. And how much do the lobbyists spend on our esteemed members of Congress? Well, again thanks to the folks at, we know that the total amount of money spent in 2008 was 3.24 billion. Now, by doing the simple math, we come up with just a little over 6 million spent, on average, per member of Congress. Wow. I hope I am not the only one who's more than a bit disappointed – and wishing I had run for Congress.

I went into the opensecrets rabbit hole searching for information on lobbying in general, but after digging for just a few minutes, I found some interesting information on one of my state's senators. Senator Susan Collins has accepted over $800,000 in donations from various industry and individual lobbyists. This is not citizen based money donated by supporters who wanted her re-elected. This money represents organizations who want favors. I did not have a warm and fuzzy feeling after leaving the site – it bordered more on disgust.

Some members of Collins' list of lobbyist donors include insurance companies (Liberty Mutual, NY Life, Met Life), banks (Goldman Sachs, Bank of America) and oil companies (ExxonMobil). It may be worth pointing out here that while Bank of America has some branches in our state, and ExxonMobil certainly has filling stations, Goldman Sachs has NO offices here. What the hell are they giving her money for? Oh, that's right, she sits on the committees of Governmental Affairs and (as of January of 2009) Appropriations. Translation – she has influence over regulation and spending. My other senator, Olympia Snowe, sits on much less powerful committees that do not influence spending and regulation like Collins' committees do. Her take in lobbying money? A much less impressive $2,000. Though to be fair, Snowe was not up for re-election in 2008, but Collins was.

This behavior of buying influence (again this is a long-standing political tradition) is repeated over and over for all members of Congress. The most powerful and those who can influence regulation get the most in donations. So who do they represent? Do they represent their constituents, or the industries who “donate” to their re-election funds? I bet I can guess. Especially since many former members of Congress go into lobbying (or working for various special interest groups) once their Congressional careers are over.

So what are we to do about this? As far as I am concerned it can be this simple – ban all lobbying. That means that senators and representatives will simply have to be beholden to their constituents – you know, the ones who actually voted for them. That would be a welcomed change from where I stand. I would like to think that my own delegation from Maine is more concerned with how I feel about such things as the bank bailouts than say, Goldman Sachs. The Goldman folks don't live here. Hell, they don't even employ people here. Why would my senator take their money if she is representing me and I would rather most of their senior leadership were in prison?

I am getting tired of feeling like unless I include a check with any letters sent to my senators, my words will go unread. The will of the people should be the rule of government. I, perhaps naively, would like to think that my concerns mean more to my congress people than the concerns of those who don't conduct business or live in my state. We need to change lobbying regulations now and remove one of the poisons of our deeply flawed political system before it can cause any more problems.

Monday, February 16, 2009

Getting to the Heart of the Matter

It's hard for me not to use analogies when talking about the current economic crisis. Since I work in the medical field, my want is to liken the crisis to a patient with multiple problems. Not all are fatal, but many are contributory to the serious situation the patient faces – that of impending death.

When a person's heart stops, it's game over. In medicine we call this a “code”. Sure, there are a handful of things we can try to get the heart going again, but all of these start basically from the premise of having nothing to lose because the patient is technically already dead. We can use various medications, electricity, blood and IV fluids all in an attempt to maintain perfusion, but unless the underlying issue is treated, we just won't succeed. No matter how much time and energy we pour into revival efforts, if we can't get at the core issue (getting the heart to pump effectively), the patient is lost.

The financial system today faces this same situation. It has not yet “coded”, but the heart rate is very slow and not moving enough blood to maintain perfusion. Treatment begins by addressing the most life-threatening symptoms and then assessing as rapidly as possible why they began in the first place. We have already dumped lots of blood and fluids into the patient (cash, guarantees, and TARP funds) – but so far not much good has come of that. There's enough fluid in the body, it's just not getting where it needs to be. Now what? Is the heart beating effectively enough? Is it pumping the blood out to the body systems?

The heart can go into a very disorganized rhythm called ventricular fibrillation. When this happens, the ability to circulate blood is so ineffective that death is very quick indeed. The best thing to do at this point is to use a shock from a defibrillator and allow the heart to reset its electrical conduction system from zero, which may allow it to come back into a normal and effective pattern. This is often done more than once and in conjunction with medications to increase the likelihood of it working. This is the big gun for us. If medications and electricity can't get the heart going after a short period, we call the code (pronounce the patient dead).

Nationalization of the banking system is like using the defibrillator. It will allow a reset to occur in the financial industry, if possible. If it does not work, we can call the code – game over. But until we try it, we will not give the patient perhaps the best chance to reset and begin to function normally. And even if this works and the banks come back, we still need to examine and treat many other contributory factors (co-morbidities we call them) or we will end up back where we are today. Getting the heart working is one thing, figuring out why the patient had the heart attack in the first place is the longer and more complicated part.

But sometimes you just don't get patients to be compliant with treatment until they face death. Sometimes they just have to learn the hard way that they need to be more responsible and take care of themselves – with the assistance of their physicians of course.

Time's getting short to act, and despite what many people believe, seconds never count - but minutes always do.

Thursday, February 12, 2009

Wondering if they can do anything right

As this week has progressed, I have become more and more doubtful about the Obama administration's abilities to help America out of the hole we have managed to dig for ourselves. Now make no mistake, the hole was there before they arrived (thank you George – you dumb ass), but that does not mean that our new leaders are any better suited than our previous leaders to get us out. In fact, many of the same people who were around when the banking and finance industries were cut loose from the regulatory leash are around now. Again. Trying to help. Supposedly.

Today came two more examples of why I doubt this crew's ability to get much done right. First, Obama was giving a speech at a Caterpillar plant and said that the stimulus bill is necessary because it will help companies like Caterpillar who have recently laid off workers, thus allowing them to re-hire some of those very people. Then the CEO of Caterpillar, himself an economic advisor to the president, steps forth and says: well, maybe not. He actually stated that they would MOST LIKELY be laying off MORE workers before any hiring could begin again. Oops.

And later today, Obama's pick for Secretary of Commerce, New Hampshire senator Judd Gregg decides to pull out because he just can't see himself working with the president. According to Gregg, there were just too many things that they had different views on and he did not feel comfortable taking the job. The Obama team spins this with a statement that Gregg came to them (not the other way around) and that he should have known what he was getting into. No mention of the possible manipulation of the vacant senate seat Gregg's departure would have created and the possibility that the democratic governor might have appointed a democrat to fill Gregg's (a republican) seat. Oh, and by the way, Obama's previous Commerce nominee? That would be Governor Bill Richardson who withdrew after it came to light that he was being investigated for contract issues in his state.

Whatever these folks are doing, they need to sit still and get their stuff together. Not only am I not thrilled about the way they are running the country, I am not sure I would let them run a cub scout meeting. And Congress is no better. The same tired and predictable partisan crap flowing out of everyone's mouths and yet so little substance coming out of anything they do (other than add exponentially to the national debt).

This country faces the collapse of the entire financial system – our banks are insolvent, personal wealth is dropping and the boomers are about to retire. We have not heard much yet about the insurance companies and their potential insolvency (coming soon to a company you have been sending checks to) and what kind of impact that will have on our system. I could go on, but you get the point.

I want everyone who has anything to do with government (all branches) to take a good hard look around. If this whole thing comes crashing down, we (the people who are losing homes and jobs as well as our wealth) are going to hold ALL of you accountable. We won't care which party you're with; we'll just care that you were not helping when you should have been. This is not a time for politics. It's a time to save our country. If you won't or can't then I suggest that you keep your eyes on the windows. When large groups of people carrying torches and pitchforks start marching toward your offices, it will be too late.

Monday, February 9, 2009

Thoughts on Accountability

While working this weekend, two of our more frequent patients (aka – frequent fliers) came in, as they normally do, looking for help. One is a relatively young woman who is a three pack a day smoker with end stage lung disease. She is on a host of medications and uses oxygen nearly all the time now. In fact, she is also on a special machine (only one step removed from a ventilator) to help support her breathing at night so she does not die while she sleeps.

All of our efforts and abilities, while admirable, are for not as this patient refuses to do anything to help herself. She still smokes, is not compliant with her medications and has refused repeatedly to be admitted to the hospital because we won't allow her to smoke while an inpatient. She knows she is dying, yet she refuses to become a DNR (Do Not Resuscitate) meaning that when she finally does come in unable to breathe on her own, we will be compelled to place a tube into her trachea and place her on ventilator. This is a futile proposition because at her level of disease, she will most likely never be able to be removed from the ventilator.

The other patient we had is a frequent visitor who comes in looking for detox as he has been intoxicated most every day of his life for the past forty or fifty years. He is depressed and often just looking for someone to talk to because he has managed to drive away all his friends and family. He is frequently loud and obnoxious, often making a scene in the waiting room and causing other patients increased anxiety. He has been in and out of every detox and substance abuse program in this state (having signed out before completion, thus ensuring his return to drinking). His pattern now is to come in and state he wants to quit drinking; he manages to stay for a few hours and then will change his mind and tell us he does not want to go to detox. He is predictable and pathetic.

What both patients have in common is that they both utilize large amounts of resources for their medical care, yet neither one is willing to contribute to their own care. They essentially get free medical care through state and federal programs because of their level of income (both are disabled) and yet they both can manage to spend money on the things that make them worse, cigarettes and alcohol. Is this O.K.? Well, in the U.S., this is too often the norm. Patients are not held accountable for their own contributions to their poor health and the rest of us pay for their poor choices.

Why do I bring this up? Because I see huge parallels between these patients and the banking and financial system in this country. The taxpayer is again being asked to support another group who is not willing to take care of itself. Banks made bad loans; ratings agencies did not do their part to make sure that securities created with these loans were assessed appropriately; insurers then insured and re-insured the securities with such creations as the Credit Default Swap (CDS) and various other instruments, again not taking into account the original bad loans that had been securitized. Now that all of this has come to light, what have these folks changed in their behaviors? In truth, not much.

At some point (and I fear we may have already passed it) we have to become realistic and make people accountable for their own bad decisions. My patients described above have both consumed more than their share of health care resources. The banking industry, for its part, has just finished off a $750 billion dollar gift from the taxpayer and now they want more. They still have assets that must be written down because of their poor decisions. Well, I for one, am willing to let them take their medicine. I have seen enough human behavior to know that if we keep giving them money, their behaviors, like bad habits, will never change.

Wednesday, February 4, 2009

The Jon Stewart Stimulus Plan

I don't have TV. I own one, it's just not connected to cable and I can't get local stations either. Some days this feels like we miss out on things, but most of the time our computers serve as our means of information and entertainment. I can watch things online that I would have watched on TV, and I can do it when I feel like it.

One show I did miss when we gave up cable was The Daily Show with Jon Stewart. He is quite simply the smartest guy out there and has no issues speaking truth to power. His is the only TV show I watch online with any frequency. On his show last week, he asked a question to a guest that basically amounted to: "why not give the stimulus money to the consumer?"

Indeed, the man may be on to something. If we have decided as a nation that we must spend what is now coming in at 1.5 TRILLION(!) dollars between the two TARP plans to buy the bad debt of banks (why?), why not take that same amount of money and give it to every man, woman and child in the country to spend or save or do whatever?

Here's the thing: We don't live in a country that makes things anymore. Sure, we still produce some things, but mostly we are a consumer driven economy. Over 70% of our economy is because we buy stuff. Think about how many factories and mills have closed near where you live. Now ask your self what has replaced them - malls. More and more communities turned to retail to save themselves from the downturn in manufacturing and as a result, malls and shopping centers have expanded at an exponential rate. Now what happens when the shoppers (us) who buy things have no money? Well, for years we borrowed thanks to easy and cheap credit. But now that has dried up and so we are beginning to not be able to pay off our debts. And make no mistake, whatever you have heard about all this, we are just at the start of a vicious cycle of default.

Back to the TARP plans - the banks have all this debt they can't value (because they can't find anyone to buy it for what they claim it's worth) and so our government and financial industry leaders (often some of the same people) have decided the BEST thing to do is to have the government (read - the US taxpayer) purchase these bad debts (at the bank's wished for cost) and get the banks re-capitalized so that they can lend again. But who will they lend to? I know I am not running out and getting another vehicle in this economy. So really, we are just giving the banks money for nothing and calling it a plan.

Now, if we really want to get money back into the economy (70% consumerism remember?) why not take that same amount of money and give it directly to the consumer? That means in a country of 300 million people, we would each get $5000.00. That's for each of us. How would most households spend anywhere from $15,000 to $25,000 dollars? Well, many would pay off debts - thus re-capitalizing banks and financial institutions like Capital One, American Express and the auto industry based finance companies like GMAC. Many would actually go out and purchase goods again like cars, white goods and other such things. Many more might utilize the money to save (again re-capitalizing banks and credit unions).

So what's the problem with this plan? Oh, that's right - the American consumer does not have lobbyists to argue for us. I mean, we should have representation, but really we don't. Our congressional delegations are too busy listening to the people who give them huge donations to help with re-election and that's not really us now is it?

But after two years of reading economists' blogs and plans, I'm not so sure that the Stewart Plan is not the best. I mean, it's hard to argue with a plan that works from the ground up to boost the economy. I never was a believer in the "trickle down" theories popularized by the conservatives of the past 40 years. It has clearly not worked out so well. So I say let's give it a try from the bottom this time. It's our money, right? Let's do something with it to help us - screw the banks.

Monday, February 2, 2009

Real Effects of the Bad Economy

It has been only 2 days since my wife's employer sent out the email stating their intent to begin some layoffs that will allow them to make budget. I had thought it inevitable, but many around here had been hopeful that it would not come to this.

As one of the largest private employers in this area, this particular hospital's decisions stand to impact more than just the people who find themselves cut in the next 2 weeks - they stand poised to adversely affect the entire community if they end up in the situation of cutting hundreds of employees and perhaps cutting services.

The biggest impact could very well be to the local population who has come to count on the 2 local hospitals to care for them. If one is forced to make significant cuts in services offered or even to close, the local populace would be forced to find services elsewhere. And the spiral effects could make that even worse as doctors, nurses and other medical providers may decide to leave this area and find work elsewhere. One less hospital, fewer services and fewer providers of care is a very unappealing thought.

As health care workers, we have already discussed the possibility of moving to a larger area that supports a larger hospital in hopes to have safer jobs. But if this area loses a hospital, who will buy our home if we move? Thus a dilemma faced by millions of Americans recently has found its way to us. Which way to go from here is not certain, but we will find our path as we always have - together.