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It's been clear for a long time that the two-tiered American healthcare system rations care.  People who have insurance get medical care…often very good medical care.  People who are uninsured…don't.

Now it's time to add a third tier…vanity patients with cash in hand.  These pampered prima donnas may be the canaries in the coal mine of the American healthcare system. The New York Times had an excellent article this week which focused on the practice of Dermatology.  Many modern day Dermatology practices are divided into two groups:  Cosmetic Dermatology (Botox, tattoo removal, hair transplants, etc) vs. Medical Dermatology (skin cancers, psoriasis, skin manifestations of systemic disease, etc). 

Vanity patients often get preferential treatment at the expense of insured medical dermatology patients.  This takes many forms, but usually means quicker appointment times (even if the medical dermatology patient has a possible skin cancer).  As the article outlines, insurance typically reimburses $60-90 for a 10 minute full-body skin cancer check.  A cosmetic dermatology patient might pay $500 for 10 minutes of Botox injections to the forehead.  As a cosmetic Dermatologist, Dr. Richey, is quoted saying:

Cosmetic patients have a much more private environment than general medical patients because they expect that.  We are a little bit more sensitive to their needs. 

I dunno, doc.  If I were a medical dermatology patient waiting for my skin biopsy result, I think I might appreciate a "more private environment" than the cattle call that is the waiting room in most doctor's offices (including mine).  To be sure, I want to be sensitive to people with crow's feet who have a high school reunion next week.  They have needs, too…and cash, lots of cash.

This is one of many problems I see with the consumer-driven healthcare model.  What happens when the people with the most money get preferential medical treatment:  quicker appointment times, better doctors, better hospitals, better medications, better defibrillators and artificial joints, preferred access to experimental protocols…the list goes on and on. 

My favorite doomsday scenario is a bird-flu pandemic similar to the 1918 Spanish Flu which killed 50-100 million people worldwide (>500,000 in the U.S.).  Extrapolate the data and you get millions dead in the US and hundreds of millions dead worldwide.  Currently, the US has about 105,000 mechanical ventilators of which 80,000 are in common use daily.  We would need 200,000 or more during a pandemic.  Who gets on a ventilator to wait out the storm would literally be a life or death decision.  Who gets to decide?  Will the mother-of-all-rationing decisions be decided by who has the most money?  Where does the law of supply-and-demand end?  Where do medical ethics begin in a consumer-is-king world?

Now, I wouldn't blame John McCain, the Republicans,  local right-wing think tanks, or other advocates of  consumer-driven healthcare for the death of hundreds of millions of people in a bird-flu pandemic any more than I would blame Barack Obama for high gas prices…oops.  Damn those murderous bastards.

Seriously, though, there are some ominous trends here.  There are perverse financial incentives in place in the American healthcare system which do not promote improved public health.  Read this article (again from New York Times) which shows how the best and brightest medical school graduates are going into Dermatology, Plastic Surgery, and Ophthalmology (LASIK eye surgery pays pretty well, don't you know).  This is not to condemn those specialties…I know plenty of Plastic Surgeons who reconstruct cancer survivors; Ophthalmologists who prevent blindness; and Dermatologists who save lives.  But should all the financial incentives align themselves in helping patients look good rather than treating disease?  Often, the medical patients seen in these practices are seen by nurse practitioners and physician assistants…while the special needs patients (ie. cash paying patients with vanity needs) are tended to by the Board Certified specialists.  You see it in my own specialty, Internal Medicine, where doc's have cash only concierge or "boutique" practices and make twice the money for half the work. (It's a good solution for the doctor and the privileged patients who can afford it…not so good for those left behind). 

It's ironic that LASIK eye surgery is the example most frequently used by consumer-driven healthcare advocates to show how "competition in the marketplace" promotes "cost efficiency."  OK.  Fine.  I guess it's great that the gentlemen making their way around the back nine at the Carolina Country Club have 20/10 vision like Tiger Woods…and it only cost them $1,000 per eye for a vanity procedure that used to be $2,000 per eye.  Milton Friedman must be pleased.

Clearly, there is a huge demand for vanity care… and in a free society patients and doctors have every right to engage in this commerce.  Sadly, we have become a nation obsessed with consumerism.  The fortunate among us, in the top 1% of earners, are afflicted with affluenza and their purchasing power is bleeding into a world of finite medical resources.  With income inequality and wealth consolidation at levels not seen in the US since 1928, the healthcare purchasing power of the super-rich is only going to increase. 

What we need most are more primary care doctors.  I'm afraid that this new class of cash paying healthcare diva's is pushing medical care in the wrong direction. 

PS. I presume most of the readers of this blog have health insurance.  Don't worry if you're not a healthcare diva and you are feeling like a second class citizen.  In the New American Healthcare Caste System there is a group  worse off than you..and it has 47 million members!

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 There are few things I dislike more than being called unpatriotic because someone disagrees with my politics.  Allow me to introduce you to John Locke Foundation blogger Jon Ham, who can apparently determine your patriotism by what yard sign you display.  Here is Ham's 4th of July offering:

Not questioning their patriotism, but …

Posted July 4th, 2008 at 6:53 PM by Jon Ham

My wife and I just got back from a July 4th walk. We walked eight miles around our neighborhood and a bunch of surrounding ones here in Durham. I saw lots of Obama signs in front yards signs and lots of American flags on houses. But I didn't see a single house with an American flag AND an Obama yard sign. Not one. Just sayin'…

UPDATE: We went on a six-mile walk today, Saturday, in the other direction from our house, and we did see one house with a flag and an Obama yard sign. 

OK.  What have we learned here.  1) Jon Ham likes to walk.  2) Jon Ham apparently left his journalistic credentials behind when he left the Herald-Sun newspapers in Durham after 19 years to join the Locke Foundation.  What, Jon, they didn't teach you anything about journalistic ethics and innuendo at Georgia?

Why don't we try this one on for size. 

Let's just say my wife and I went walking in our neighborhood on the 4th of July in 1980 and again in 1984.  We saw lots of Reagan signs in front yard signs and lots of lawn jockeys and confederate flags.  I'm not saying that EVERY single house that had a Reagan sign had a lawn jockey and a confederate flag or some other sign of overt racism, but some did.  Just sayin'…

UPDATE:  Too tired to walk today.  Listened to Reagan kick-off campaign with speech on "states' rights" in Neshoba County, Mississippi where three civil rights workers were slain.

If you think Im being too harsh, well…maybe we should just call this "satire," albeit poorly executed… much like this now infamous magazine cover.

Besides being fun to write, there is a legitimate point to this post and here it is: hypocrisy should be exposed wherever you find it.  John Hood would like to have you believe that the John Locke Foundation is "non-political;" a high-minded "think tank" that "employs research and journalism" to "transform government."  Hood ought to read his own blogs.  It ain't high-minded, it ain't cerebral, it ain't journalism, it ain't research (unless you call cribbing recycled posts from Heritage and AEI "analysis"), and it sure as hell ain't non-political.  They are knee-deep in politics over there, and it is usually of the most divisive kind.

It's an election year, folks…it's gonna get ugly.

(Click here for a larger image of Jon Ham's hero) 

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The Medicare vote in the Senate this week, highlighted by Ted Kennedy's triumphant return, was encouraging for proponents of universal health coverage.  At least, that's how Paul Krugman sees it (and I agree):

But the vote was bigger than the theatrics. It was the first major health care victory that Democrats have won in a long time. And it was enormously encouraging for advocates of universal health care.

Ostensibly, Wednesday’s vote was about restoring cuts in Medicare payments to doctors. What it was really about, however, was the fight against creeping privatization. Democrats finally took a stand — and, thanks to Senator Kennedy, seem to have prevailed.

Ezra Klein weighs in with this:

From a sheer political power perspective, an alliance between Democrats and doctors could prove a very powerful thing indeed.

Next up, did you hear about Elizabeth Edwards new position?  She is headlining Health Care For America NOW, a 40 million dollar campaign to promote legislation which guarantees quality, affordable healthcare for all.  Their website is here

And finally, if I were Harry Reid or Nancy Pelosi I would put SCHIP back on the table.  It seems others are thinking the same thing.

Yup.  The prospect of universal health coverage just got a whole lot better this week.

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Congress will resume debate today over the bill to prevent a 10.6% pay cut to doctors who provide care to Medicare patients.  Details here.  The pay cut took effect last week, July 1, but processing of claims has been delayed for two weeks in hopes of a solution.  Military families, who receive coverage under the federal program Tricare, are similarly threatened.  Tricare payments are linked to the Medicare fee schedule, so any threat to Medicare endangers the Tricare patients as well.  Remember: most physician contracts (public and private) are linked to Medicare.  If Medicare cuts 10% then total revenue will be decreased a similar amount.  There is another fee cut of 5% scheduled for January 2009.  I can promise you that a 10-15% cut will seriously decrease access to physicians for Medicare and Tricare patients.

The bill passed the House 355-59, but was stalled in the Senate by one vote in failing to attain the required 60 votes.  All 40 "NO" votes were Senate Republicans (including North Carolina's Richard Burr).  President Bush has said repeatedly that he will veto the bill, so it is likely that a veto-proof 67 votes will be required for passage.

In support of the bill are AARP, advocacy groups for military families, and the American Medical Association.

Why would Republicans risk screwing military families, the elderly, the disabled, and doctors (not to mention taxpayers) in an election year?  Because they care more about corporations than they do about people, that's why.  In this case, it is health insurance companies that are receiving the Republicans and President Bush's loving embrace.

The sticking point is that Democrats want to pay for the bill by reducing the corporate subsidies provided to insurance companies to privatize Medicare.  On average, taxpayers pay 13% more for private companies to provide benefits that are currently available under traditional Medicare.

You heard me right: government-run traditional Medicare outperforms the private sector.  We pay approximately $1,000 more per patient per year for private insurance to manage Medicare patients.  The market has spoken, but Richard Burr, George Bush, and the Senate Republicans don't want to hear it.

There is no good reason to continue subsidizing private companies to provide coverage already provided by traditional Medicare.  It is clearly more expensive, and there is no evidence that private companies deliver a better product.  In fact, private insurance companies have to use unethical hard-sell scare tactics to sell the damn things.   There are numerous myths by the insurance lobbyists to be debunked here (including the myth that low income or minority beneficiaries in rural or inner-city localities would be adversely effected).

By far, the best analysis of the facts regarding this bill can be found here. 

Do yourself a favor and read it.  Then contact Richard Burr here and ask him why he favors insurance companies over his constituents: military families, elderly, disabled, and doctors.   

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Imagine my surprise today to open The New York Times and see a near full-page ad for a conference co-sponsored by our own John Locke Foundation.  It is the "International Conference On Climate Change" at the Marriott in New York City, which promises to "prove there is no scientific consensus on the causes or likely consequences of global warming."

This appears to be more of a public relations stunt than a scientific conference. 

How do I know this?  The organisers say so in their invitation letter to speakers, where they concede that "the purpose of this conference is to generate international media attention…"

Furthermore, the presenting organization is The Heartland Institute.  This bogus group is described as a front group for the fossil fuel industry, as well as a for the tobacco industry.  Now that's the kind of work that will make you feel good about yourself!  Go here to read all about them.  The Greenpeace project, ExxonSecrets, notes that the Heartland Institute has received $791,500 from ExxonMobil since 1998. 

For a hilarious opinion regarding this "conference," go to this link titled: "What If You Held a Conference, and No (Real) Scientists Came?".  Among other things, you will learn that they are paying for legislators to attend the conference, that presenters are receiving a $1,000 honorarium, and that last year the American Enterprise Institute offered $10,000 cash for scientists to dispute global warming.  AEI has received 1.6 million dollars from ExxonMobil.

And before anybody from Locke tells me to "look at the data, not at the source," let me remind them about peer review.  While peer review is not infallible, it is still the gold standard by which scientific inquiry is judged.  And while there is still much to learn in regards to global warming, the peer reviewed  scientific consensus is not in doubt.  Go here to read about the true scientific consensus regarding climate change.  From 1993-2003, all 928 papers published in refereed scientific journals regarding climate change were reviewed.  None of the papers disagreed with the consensus position.  I don't mind saying I don't understand the subtleties of climate science, but shouldn't we be listening to the scientists who are willing to put their research on the line and be reviewed by their peers? 

It's that simple.  If you are a reputable scientist, submit your research to a credible journal and have your peers review it.  There is a proper forum for the discussion of legitimate scientific research, and the Exxon-funded Heartland Institute is not it.   Why not use the same formula medical researchers use?  Legitimate researchers submit their work to The New England Journal of Medicine for review, not to John Stossel at ABC's 20/20.  In the too-good-to-be-true category, noted Heartland Institute global warming scientist John Stossel happens to be one of three guest speakers at Locke's fake conference.  I wonder what new data he will be presenting.

This "conference" is typical of right-wing propaganda.  The (dis)information serves as a prop for the ideology.  These so-called scientists are not enlightened and embattled modern-day Galileo's, swimming upstream against entrenched Dark-Age conventional wisdom.  No, they are more like a carnival barker on the State Fair Midway, using illusion and innuendo to appeal to your most base instincts.  Remember that sick, creepy feeling you had when you finally stole a glimpse of the bearded lady?  Today's attendees at Locke's fake conference ought to feel the same way, knowing they are participating in something they shouldn't.   Come to think of it, I get that same sick, creepy feeling whenever I read any "research" from Locke or Civitas.

Say it one more time.  It's not about the science, it's about the ideology. 

P.S…Rob Schofield notes in his excellent essay here that Locke and Civitas want to be known as "idea shops."  I'm not sure how co-sponsoring a fake conference will help.  Never fear, Lockeans, the world is simply teeming with bad ideas, and most of them have found a home in your shop.

P.S.S. Before any researchers at JLF get hysterical because I panned a conference I did not attend…do me a favor.  Send me their peer reviewed research findings, and a list of their funding sources.