my real healthcare plan

Everyone should take out a high deductible major medical policy to cover catastrophic stuff, big stuff, then have enough money available either liquid or line of credit, to cover that deductible should it be needed. Then we should pay out of pocket for our "incidental" stuff like sinus infections, bronchitis, sprained ankles, prescriptions, shots, checkups, etc. We could use a health savings account, use pretax dollars, and be able to "roll over" unused balances from each year if available. Then we would become better consumers of healthcare and not the entitled brats we've become. We would think more carefully about the MRI that's ordered, the prescription that's given, whether we should get generic, etc., and be responsible for our own healthcare costs. For families having kids, they might save up a few years' worth of savings from their good health to cover the costs of a new baby, and then the catastrophic plan would cover a premie with big needs or a high risk pregnancy. We would be more likely to have mom come move in with us, maybe we would even build on an addition for her and hire a nurse/aide to care for her at her home or ours, if we compared the costs of a nursing home and the heartaches of such an arrangement with this "radical" though time-tested method of caring for the aged.

Sure, you could go with the car insurance idea to decide how much insurance you could get for the money, but the idea of using the difference between the premium on your major medical policy and your "cover it all including prescriptions" plan to put into a health savings account with the ability to roll it over and even get interest on the money would help the elderly pay for their long term care since they've been paying into this for years and haven't been counting on the government to manage it, they've been managing it, and if they want to go to the Bahamas to retire to a seaside village "nursing home" and they can afford it, so be it.

I'm not political enough to know who's for this, if either of the candidates is, but I'm pretty sure it's not Barack Obama. 

As a physician, I should become more like our colleagues, the veterinarians, and know how much things cost and be able to give people a reasonable idea of how much things will cost and let them help in the choice. If there's a cost difference for the same procedure at one place vs. another, they should know. We would have a big element of change on our hands, both physicians and patients. For this generation, which has grown up saying "sure, go ahead, I've got insurance" to find out how much something is going to cost and decide if they should get it or do it, is going to be uncomfortable at first. It's going to affect malpractice because if I recommend something and the patient doesn't want to do it (like vaccines now!) then has a bad outcome as a result of choosing not to do it, I'm liable under the current system, even if I was adamant about them needing to do it or get it or whatever, and documented my advice. Maybe videotaping of consent will help this. You get taped turning down my advice. Now of course if my advice results in a bad outcome...I'm still liable and should be. And many things aren't black and white, and the definition of a bad outcome will have to be ironed out. Oh, so many things, but our consumer economy can get through it, we just have to quit being ostriches as far as how much things cost (physicians and patients) and be willing to present and accept options.

Unlike our friends the veterinarians, though, one of our options (at least currently) isn't going to be "or for this amount, we can put X to sleep". I'm a little afraid that time may not be far in the future, especially if humanist atheists are running the system. But I digress...

But I need to know!

Very often, in the course of a day, a mom will bring a baby who is fussy. Or who has a fever, or isn't sleeping. It's amazing how happy they are when I find something wrong! Or rather, how disappointed they are when I don't. It's better for the child to have an ear infection to explain the problems than it is to have some viral thing without a specific name causing all the trouble. Regardless of the fact that the virus will pass without treatment and the ear infection will likely require antibiotics (for more on this, see future blogs about antibiotic use). Oswald Chambers, in My Utmost for His Highest, my favorite daily devotional, said on July 18 "We command what we are able to explain, consequently it is natural to seek to explain". In this instance, I think his words ring true. An ear infection is a known entity. Viruses are not. Some people will say "it's just a virus" and be happy or disgusted that their child was lucky enough not to get some infection that had a name or a treatment. The truly paranoid, of which there are a growing number, think of all the viruses that strike fear into the hearts of parents, like West Nile virus, or measles or mumps, or HIV, to name a few. A balance between disgust and fear is a reasonable position. It just is interesting that parents, especially closer to the weekend, are happy that their child has a "known" problem, rather than a nebulous one that is not as predictable or treatable, even though their child will live through it and be fine after.

a behavior management metaphor

OK. I talk to parents daily and discuss behavior management. I try to teach to ignore certain things that aren't good if they aren't trends in that child's behavior but are more just episodes. But I couldn't/hadn't come up with an analogy until just the other day. And it really applies in several areas.

Our new employee lives in an apartment complex. They have assigned parking spots. They have the right to call a number and have a car towed that is in their spot. They pay for that right in their rent. So, someone parked in her spot. Once. It was a big truck. She debated calling the number for the tow, but decided against it for a couple of reasons. One, it may have been a mistake or ignorance on the part of the big truck owner. Maybe he wasn't informed of the policy, maybe he had an emergency and the seriousness of that superceded the importance of the policy at that point. Maybe, if she talked to that person, she would find out. Her choice was to call or just deal with it and park somewhere else. But, even though she considered the possibilities above and chose not to call, another reason for not calling was that she was afraid of the response of the person driving the truck. He would know who called because the spots are assigned, and he might cause her some trouble if she exercised her rights. So, she didn't report it and let it go. And it's only happened once. Did she make the right choice? Yes. Were her motives good? Yes and no. Or maybe just yes. However, if the truck continued parking in her spot because of her lack of response, if it became a trend rather than an episode, she needs to report it and take it to the next level. Regardless of the possible ramifications? Maybe. She should definitely consider these and make plans to control them to the best of her ability, and she should find out who this big truck's owner is and why he's parking in her spot. Then, if he is just doing it because he can, and he refuses to cease and desist, she must exercise her right to the spot and take the necessary actions.

Can you see the analogy between this and a child's behavior? Maybe he forgot to take out the trash like you told him to. Maybe she didn't remember to make her bed, or to call when she got to her friend's house. But if these things continue, and the rules are spelled out and communication has occurred and the behavior begins to be a trend rather than an episode, the parent must take action. Action taken when it truly is an oversight or accident is counterproductive and often results in the attitude of "heck, I get in trouble no matter what I do, so I'll just do what I want because my parents are controlling jerks and yell at me when I make a little mistake". Whereas, if the episode is overlooked and the child later realizes it, and is remorseful ( I know I'm asking a lot of the imagination), then great strides in trust and relationship have been made. 

So...it's ok to find another place to park every once in a while, even though it is your spot and you have every right to claim it for yourself. You may end up with a new friend or a relationship that you didn't expect, because the owner of the truck really didn't mean to park in your place and he's really surprised and grateful that you treated him with respect despite his behavior, or his perceived behavior. Motive is the key. Many are looking for reasons to get mad, to exercise their rights, because they see the affront as being toward them vs. an honest mistake or an episode of behavior. Parents have to be grown up enough to distinguish between episodes and trends, to be willing to park elsewhere if needed, or to call for a tow truck if needed, and to not be afraid of the child's response to this and the damage that child could do if called to account for the behavior. But boy it's easier to call for that tow truck if you'd made every effort to communicate with the child and only have them towed if they are unwilling to fix their problem. Maybe on another blog we'll discuss what to do when the tow truck is called. 

"be like a child..."

Being like a child seems to be getting harder these days. It's always been hard for adults to be like children, but now it's hard for kids, too.

I saw a first grader last month with a "to do" list. Anxiety related problems are more common than ever in children in my practice. GERD, breathing problems, stomach aches, headaches, they are all at least potentially and in part anxiety related disorders.

Kids have been told to have good self esteem, and the trouble is that with self esteem comes self awareness, and with self awareness comes the awareness that they're not as good/perfect as they've been brought up to believe, and that stresses kids out. What's the answer to this problem? Should parents stop praising their children? Should we stop preaching self esteem and be more honest in our appraisal of our kids while emphasizing unconditional love? What would that look like?

"I love you no matter what, so you don't have to worry about that. No matter what you do, I can't NOT love you, so chill and rest in that assurance. Now, about that...grade, performance, attitude, behavior, etc..." Kids know they're not perfect, but as my wife quotes often, "a lie told often enough becomes a truth, even if it is a lie". So, a realistic view of our children is now considered demeaning and limiting and "not allowing them to realize their potential or explore their boundaries".  Pretty much you're bucking the trend if you try to raise your children with a true self awareness that includes their moles and warts and accepts those as a part of a loved person but that some people are better at some things than others and not all kids are really as "special" as they've been taught in school - just by breathing they automatically get credit for being the next rocket scientist or Tiger Woods and people push them to expect things from themselves that are unreasonable, then they're stressed and depressed and they go into therapy where they're told that no matter how broken they are it's not their fault and there's medicine to help their alleged chemical imbalance and when that doesn't fix the problem they again go to therapy where another diagnosis is made to justify another unnecessary and dangerous drug and the cycle continues until they either grow up and become realistic or grow up and become more unrealistic and expect others to adjust to their weirdnesses since it's obviously the other people that have the problems, not them, because they're "special", their parents and teachers told them so a long time ago and dadgummit, they believe it. Whew! My high school English teacher would dissect that sentence and use a whole red pencil just to mark the errors, but it felt good to vent.

OK, childhood does still exist, but I just found out about it. A 13 year old friend of mine described staying out til 10:30 the other night playing dodge ball and hide and seek with other kids in the neighborhood. Thank goodness that still happens. Amazing how I don't have those kids in my office for stress-related disorders like the kids who just got back from their soccer tournament at 10:30 and fell into bed to get up and travel to another tournament tomorrow where they're likely to get yelled at for not playing as hard as they can or not played at all because they aren't scoring like another kid on the team. Oh, don't get me wrong, to play everyone on the team for the exact same amount of time without regard to performance is to play into the above self esteem game, but I'm talking about the kid who comes and practices and tries and has a good attitude, but needs a chance to prove himself but can't get it because every game is too important to risk losing to give a kid a break. Enough on that, most of you know my opinions of youth soccer, or any team sport in young kids for that matter. But childhood is still out there to be had, and I'm glad, because the lightning bugs are still there and the woods are there and the imaginations are there to build the fort and make the club and we, as adults, must let kids do these things more, even if it's a little scary, because if every minute of every day of your kids' summer is planned with camps and lessons and tournaments and trips to Disneyworld where they better have fun because it cost you a bundle and they better not mess it up and it's more about you than it is about them because you're trying to be a super parent so you can talk to other super parents about how super you all are, while leaving your kids in planned activities because God forbid they should have any free time or they might not realize their potentials, then you're going to have Harry Chapin's "Cat's in the Cradle" playing at your funeral and your kids are going to send flowers but they're too busy maximizing every opportunity to come to pay respects and say goodbye. Ouch, that hurt. Sorry. No, I'm really not. I'm making a point. Sometimes one has to go over the edge to make the point, but the point needs to be made that kids need to have time to be kids, lest we begin needing to put prozac and adderall and nexium in the water supply because we're all depressed, distracted, and have indigestion.

healthcare plan 2

OK, I know it won't work to make health insurance just like car insurance. You can drive safer and have lower rates, or have wrecks and tickets and get kicked off your insurance, and even if you're "innocent" in a wreck or problem, your rates still seem to go up. That doesn't seem feasible for health insurance. Too many things are "innocent", especially with kids, who are at the mercy of their parents, and to be too restrictive in the care that some parents seek for their children would be to invite disaster. So we probably shouldn't punish people for health problems but...and in this I'm the one I'm talking about...the health problems we bring upon ourselves by doing things we shouldn't do and know better, those might need to be grounds for raising our premiums. These are the tickets, speeding, reckless driving, DUI, etc. Some are forgivable if only in their commonality, but some are downright bad not only for the person doing them but also for those around him.

I obviously wax philosophical at times, quit laughing, and I need to be grounded by wisdom vs. overthinking. A friend did this for me yesterday. We were discussing (I was spouting off, he was apparently listening) whether the chemicals in plastic were a concern since we're all drinking from plastic of some sort all the time, it seems. He said "until people aren't obese and they are exercising at least a little and they take care of their type 2 diabetes and high blood pressure and high cholesterol, I think it's stupid to worry if the chemicals in plastic are harming us. We're harming us!" I took liberty with the quote, his was more pithy than mine and I don't recall the exact words but the message was loud and clear. We strain at a gnat and swallow a camel as Jesus said. The chemical issue is the gnat, the obesity "epidemic" is the camel. Sorry, but some need the explanation of the metaphor. 

So...perhaps the equivalent of "points" in the car insurance industry - where our records reflect our wrongdoings like speeding tickets and the like and our premiums are up and down commensurate with the number of points - should be our weight, waist size, BMI, you pick the measurement, and make it broad (no pun intended) to account for those of us who are "big boned" but not really obese (yeah, right). Truly there are persons whose weights or BMI's look to be out of whack but they are in shape, etc., and need not be punished. Perhaps to justify one's size, one must come up with laboratory results that reflect the state of one's health - so if your BMI is over 30, but your cholesterol and triglycerides and hemoglobin A1c are in acceptable range, you're exempt from the premium increase. Life insurance companies sure don't mind raising premiums if you're high risk. So, if your weight or BMI is OK, you're good to go on the "no points" premium, but you're rated higher for obesity, etc., if you are, in fact, obese and can't provide good evidence that your obesity hasn't apparently endangered your health yet. I guess you'd have less money to spend on food if your premiums were high, then you'd lose weight, right? Wrong. Because good, healthy food, unless you grow it yourself, is at least allegedly more expensive and doesn't keep as long as the frozen tv dinner with 40g of trans fat per serving. 

This little aside is to let people know that I realize you can't just penalize people for having bad health by charging them more for health insurance. Too many illnesses are not directly the cause of anything we know anything about. Babies born with birth defects through no fault of the mother or father. Premature babies who just happened to be born a few weeks early and had to spend expensive time in the intensive care unit. Someone gets run over or into by a drunk driver. 

Realize that anytime we begin to discuss such things the issue of euthanasia or "letting someone die" or attaching quality of life potentials as parameters for who lives and who dies begin to surface, since an entity, likely the government but just as easily Blue Cross and Blue Shield, will be determining who pays what for health care and how much should any one person get, etc. Tough questions. Not for us to decide. For God to decide, but God, though He hasn't been consulted on these issues in our science for quite some time, often has different ideas than our human wisdom. We've taken Him out of the equation, and what's funny, even sometimes I, as a Christian who should know better, forget that He is sovereign over all. I have a parenting technique I tell parents about called the "good luck" theory, I think I stole it from Foster Cline and Jim Fay of Parenting with Love and Logic, but oh well. I think God knows about the "good luck" theory. He's saying "good luck", go ahead and try to decide who lives and who dies and who has what cancer or disease and try to cure it and screen for it and delve down into the human DNA code and see what you think you can do with it - I created the whole thing! Try to make things perfect here on earth by eliminating disease and suffering and starvation and toxins and try to have your cake and eat it too by flying and driving everywhere and using food for fuel and...good luck. The next line after "good luck" is "I'm sorry" when things turn out the way the parent knew they would. God has infinite patience, and I think He's saying "I'm sorry" to lots of things right now. There was a good Dilbert recently where the boss presented an idea that we could turn fresh water into oil - and thankfully Dilbert saw through the solution to the problem and asked "wouldn't that turn the world into an uninhabitable wasteland in the long run?" Someone needs to follow several lines of medical and other scientific "logic" out to the long run. 

My point there was that we really have no ultimate control over things, we just think we do. We play around with genes and chromosomes and talk about stem cells and cures for diseases, but in reality, we're kids playing in the sandbox while the One who made the whole beach is just watching and waiting and letting us think we can do it our way, and what's worse, that our way is better. At least that's what many think. That the way God's had it going for several millenia is a bad deal and that we, as humans, are here to save the day! We've got a better plan.

Back to health insurance, sorry. We need to quit requiring every test for every thing there is before we act on anything. I'm all for making sure a diagnosis is correct, but did you know that there was disease before the MRI was invented? And people somehow managed? Doctors made diagnoses by taking histories and doing physical examinations and thinking and studying, whereas now even if we do the H and P and actually think and study, we have to have our decisions backed up by test after test, so after a while, it's easier just to do the test and forget the first part. That's where much of medicine is, and the public is partly responsible. It's like depending on a calculator vs. learning simple math. Sure, the calculator's nice, but if the basics behind it aren't known, a vital piece is lost. Or even more pertinent and current, keeping phone numbers in our brains vs. our phones - once we start using the phone to store numbers under peoples' names, etc., we lose the memory of that number and rely on the machine vs. the mind. In medicine, the public currently is bowing to the prowess of the equivalent of a synthesized computerized piece of music over the art of a gifted performer. We want the test, not the doctor's opinion. But what's funny is, the patient wants the doctor, too. They want to know what I would do if it was my kid. Or my dad or mom. They can search out the diagnosis on webmd and they still want the doctor to confirm it or refute it.

So, as far as I'm concerned, we still need doctors. We still need hospitals and medicines and tests. Don't get me wrong. I like storing numbers in my phone. I just don't want to lose the ability to remember them myself. The art of medicine is to decide when to go with the obvious diagnosis instead of covering one's ass with a zillion dollars' worth of tests. And this is where both doctors and patients will benefit in a good healthcare system. The doctor who is able to practice good medicine, I mean good medicine, with a minimum of testing and treating, would be rewarded, and the patient who goes to the doctor for a real problem vs. a problem they think they might have and demands a bunch of tests is penalized with the doctor who orders a CT scan for every headache and a CBC for every fever. Just because one can order and do a test doesn't mean the test is needed. We've lost the doctor/patient relationship over the past 2 decades due to insurance rules and tests. 

So...we need to remember Who created us and that He has a plan. We are apparently being forced into at least discussing a "new" health care plan, and depending on the winner of the November election, the discussion will differ, but the outcome likely will not be that different. We are talking about doctors and patients here, and neither handles change well, especially change that feels like it's forced upon us. It's amazing that no insurance or government entity forced the concept of the "urgent care center" upon us, but I would venture that these "docs in the box" are the fastest growing healthcare providers around. Obviously, the drug companies and the doctors who write for their products are paying no attention to the fact that people are having to spend more and more at the pharmacy for their medicine. And as newer tests become available, patients demand and doctors order (or is it the other way around) ultrasounds so expectant parents can have daily cell counts on their new embryo! Or MRI's on joints that are sprained, and then instead of a "sprain", which sounds mundane and survivable, they have a "torn ligament" or a "stress fracture", which sounds (and is) more expensive. And guess what? The insurance company will pay for more physical therapy for "stress fractures" than shin splints. So, we're shooting ourselves in the foot, and we probably should stop. It's going to be hard, it's hard for us to give us something then tell us we can't have it anymore. There will be so many loopholes in any new healthcare plan that it may need to be administered by the IRS! 

OK, that's enough. Just rambling. Maybe I can take off on one of these thoughts and go for another hour or two, but I'm done for now.

my healthcare plan

OK, I'm not running for office here, I'm just ranting and putting some thoughts together formed from 20+ years in healthcare.

Why can't health insurance be like car insurance? Or homeowner's? You have to get it, by law, at the car insurance. To get a tag for your car you have to show proof of insurance. Sure, some fake it or lie about it, but most (I think) really have it.

So make it a law that people have to have some level of health insurance. If they qualify by income level like for DHS support, they can get it for free. But they still have to have it. I have told people for years that they should buy a major medical health insurance policy with a high deductible, to cover catastrophic stuff, and then use the money they save vs. a full coverage policy with prescription drug coverage, etc., to pay for their occasional doctor visits and medicines. 

You may say, "but people won't be able to get the drugs they need or the tests they need or the medical care they need...". Here is where "need" needs to be defined as true need and not "want" or "expect".

The proliferation of prescription drugs to "fix" all our social and personal ills is a good sign that there's money to be made in this business. It's like all the restaurants going up all around, people want to eat out, and they do it a lot. And people want pills, a lot of them. Driving through town today I saw evidence of so many things that are "wants" and not "needs" and they are unashamedly marketed out there on the street for people to see and "want" some more. Before I go on, I should tell you that I'm like the guy in the AA meeting standing up and saying, "hi, I'm Kelly, and I'm a 'wantaholic'". I see these things because I'm looking for them and they tempt me. Maybe if I was closer to the "need" stage, if I had little kids, especially, I'd be less likely to be going off on these things, but I don't so I am. Exotic play grounds for the backyard, all redwood and bright plastic with slides and faux rockclimbing attachments, the kind you used to only see in neighborhood playgrounds or God forbid, school playgrounds. I'm talking big monstrosities that look like they'd take a crane to get them in the backyard or several weeks of putting tab A in slot B and then screwing it all together, a nightmare in my opinion. Well, I digress. Well, except for pets. Like kids, there are things available for pets that someone visiting our country from even 20 years ago would have laughed at in amazement. Play groups for pets, dog parks, and supermarkets with only pet stuff, most of which no pet would even care about, much like much of the junk available for kids who'd rather just have a stick and some dirt and maybe a tree to climb and a bike to ride, but we "need" this stuff - because it's available and for sale.

Back to the health insurance issue, after my rabbit trail and segue back in - most of the medicines and tests like MRI and 4D ultrasound and designer blood pressure/cholesterol reducing drugs, reflux medicines, antidepressants, stimulants for ADD, etc., are really "wants" disguised as "needs". They are available, we know someone who has had one or takes one and so we think we must need one, too. And besides, they're for sale and all you have to have is a doctor's order, or at least that's what the commercials say. Commercials for medical stuff - another thing that a visitor from the not so distant past would find amusing, until he saw how well it works. Sure, the drug companies used to buy doctors by buying lunch or golf trips or whatever, and they still do, only mostly with food now, and "consulting fees" or "speaker fees" by having one of us review an article about their drug and then talk to our colleagues about them at a fancy restaurant. And this is paying off, I have no doubt. But nothing has paid off as well as "just ask your doctor about...". The 4 hour erection on the ED drug commercials is the best way I've ever seen a drug's potential side effects sold as a subliminal tease. I remember a show on "commercials you'll probably never see" and there were these 2 boys about 8 years old who are talking about what they're saving their money for and are overheard by their mother when one says "I'm saving up to buy OB tampons" and the other one says, "OB tampons, why?" and the first one says, "I saw on TV that if you buy OB tampons you can go swimming and skiing and biking and hiking..." and of course the mother cracks up quietly laughing. Commercials affect different people differently. And instead of eating right and exercising, I'd like a pill to make me get in shape and lose weight or lower my cholesterol and make me smarter without studying and a procedure to erase the wrinkles of aging and suck the cellulite out of my thighs and...

So we're now selling medical care as a "need" when most of it is really just a "want". That a CT or MRI is "standard" care for a painful shoulder or knee or for a headache is a recent phenomenon. To some degree driven by malpractice fears, doctors are able to justify an "overevaluation" of fairly common problems. The thought process of diagnosis is often short circuited by all the tests. That's a different topic, sorry. But the idea that our insurance should pay for whatever whenever is a fallacy that has gotten us to this point, and we're going to have a hard time getting off this high center of expectations from the public. I'm not going to argue that healthcare is a 'right' in our society. It is, because we say it is. But how much is 'right' when it comes to healthcare? Is there such a thing as too much? I think we all would like to think that at least some healthcare is a good thing, so there is such a thing as too little, but too much? The way I see it, we're well into a 'too much' phase right now. Too much medicine, too many opportunities for elective procedures, too much screening (in the name of health, but in reality a ploy, many times, to generate business for a particular segment of the healthcare industry), too many required tests, too many lawsuits for too much money. But we've come to expect this level of 'care' and it's going to be hard to cut back. I tell parents all the time to start small and work up with praise and rewards, etc., or they may get to the point where there is no reward large enough to make a child want to do something to get it, because the child already has it all. We are those children, and in fact, we have watched this thing grow right in front of our eyes since most of us were children. I can't tell you how many times a parent says something like "my mom never took us to the doctor unless we were dying". So why didn't she? Was there not a doctor around? I don't think so, because then they'd say, "we never got to go to the doctor when I was a kid because the nearest doctor was too far away". Was there not enough money? My dad was a doctor. I remember him charging $10 for an office visit and taking items for barter if the patient couldn't pay. Money for a doctor may have been somewhat of a luxury for some, but it wasn't the astronomical figure we see now, even with inflation. What is responsible for this rise in cost? You don't have to pay for it anymore. You pay for insurance and your insurance pays the doctor. It's like going out to dinner and not having to pay. Or, more realistically, you don't have to pay while you're there, you may get a bill for part of the meal later, but it's distant from the actual meal so it seems separate. Which gives rise to people forgetting how good the meal was and how they ordered dessert and an extra drink at the time because they wanted it and it didn't cost them anything anyway, so when the bill comes, they argue about paying it. I could run this analogy's legs off if I desired, like how you could go to certain restaurants and have dinner and have it paid for, but for others you had to pay, or at least pay more of the bill. And you could only order certain things unless you had prior approval. But I won't.

Automobile insurance is different. The expectations are different from the outset. If you want, you can only pay for liability insurance that covers any damage to others but doesn't fix your car. You don't expect insurance to pay for filling up with gas or getting an oil change or a brake job or even a new transmission. You have insurance to pay for damage done in accidents. And you don't even want to turn in many claims for that unless you want your premiums to go up. So you pay for the repairs out of pocket. How would this look in health insurance? 

Maybe we could buy an insurance policy that would cover big stuff, like accidents or severe illnesses. Then we could pay for the incidental stuff out of our own pockets. I'm cutting my own throat here, so be nice. If you had to pay for your baby's checkups and shots, you'd be looking for the best deal you could get. Sure, you want the best for your child, but if Dr. X charges 25% less for his checkups than Dr. Y, you're at least going to go see for yourself. This is the WalMart mentality. The best for less, or something like that. So, Dr. Y either has to convince you that his fees are reasonable due to better service or something else he provides that Dr. X doesn't, or you're going to change doctors. The same thing goes for procedures, and medicine, and vaccinations, and on and on. Capitalism at its finest. Ouch! No longer would there be this built in fee schedule based on what the government will pay for things. This is a pretty easy thing to see, I think. Competition is good for a business. It makes the consumer the driver of cost more than the government or big business. There is a place for the profession to police itself and the consumer needs to know that he doesn't know as much as the professional in some instances. In the same way that I take my car in to be fixed and I don't know what's wrong or I don't know how to fix it or have the equipment to diagnose and repair it, I have to rely on the expertise of the expert in this area. To some degree, I am at his mercy. But one develops relationships which are built on the assumption that the mechanic can do the job I'm paying him to do.  If he does it well and charges a reasonable price, I'm usually happy to pay it. Sure, I could go to a different mechanic for every problem, but having one who knows my car, and knows me and the way I drive and what I use a car for, that's important. In healthcare, as I'm sure in car care, there are many opinions out there that the 'experts' are ripping you off, making you sick, not doing you right. This lack of trust is natural when one is spending money on something that isn't always tangible. Like the story of the electrician who comes to a house to fix some appliance and all he has to do is push some button or tighten a screw, and when he gives the homeowner the bill, the homeowner gripes that "all you had to do was..." and the electrician responds by saying that the homeowner is paying him for the knowledge of which button to push or which screw to tighten, not the actual work. 

So, as a pediatrician, I would need to be competitive in my fees or provide something special that others didn't, in order to have higher fees than the guy down the street. It's the steak dinner at Denny's vs. the steak dinner at Outback vs. the steak dinner at Boulevard Steakhouse. There's a difference. Yes, it's all steak, it's all cooked and served to you, but some prefer to move up a notch or two in quality or service and are willing to pay for that difference. So there will be doctors who do the basics and ones who provide a level of care above the basics. One would hope that each would be reasonably similar in their ability to diagnose and treat common problems, and the difference might come in the amount of time one spent with the doctor or the waiting time was less or the office was nicer and cleaner and friendlier. There will be, and already are in some places, doctors who provide a 'concierge' level of service. They don't accept insurance payments and are pretty much on retainer for a certain number of patients who have access to this physician when they want it and don't have to put up with the 'regular' stuff the 'regular' patients deal with. This will become more common. 

So, we are not cars. We don't just decide not to fix someone and sell them or scrap them. That's illegal, immoral, and generally distasteful. We don't get a 'lemon protection plan' and we can't just get a new kid when the old one 'wears out'. And we're not pets. We can't just decide to put our kid to sleep if he's got some illness that's going to be difficult or painful or expensive or all of the above. But there are similarities. We can use 'premium' gas and extra long life motor oil and the best spark plugs and really pamper our kids just like our cars. We can buy the best dog or cat food and have them groomed regularly. But those are our choices and we pay for them. 

We get diseases that must be treated. We have accidents. We need doctors and nurses and hospitals for some things. We need MRI sometimes. We need medicines sometimes. But do we need them as much as we think we do? What if we paid for it? Out of pocket, prices listed on the 'menu' at the desk, optional extras like prescriptions called in or faxed vs. written, shots with clean needles (just kidding), phone calls returned the same day for one charge, within a week, different charge, sort of like shipping charges. 

This is all well and good for most of my population of patients. I think they'd find that they need me far less than they think when they had to pay out of pocket. They'd be less demanding in some ways, more in others. They probably wouldn't come in for a cold as often. They'd wait and see if a child actually got sick before they came in, and they'd have an opinion as to what drugs we used to treat the child (more than they do already). This shift of responsibility to the patient would cause many changes in my behavior and that of my patients. Do you want to see the doctor? That's this much. If you want to see the nurse practitioner, that's this much. If you want to see the NP but have her consult with the doctor, that's this much. Would you like an estimate to fix your problem or do you want us to fix it while you're here? This is already happening in consultations with some specialists. It would be a different world. I would have to earn your business because there's another doctor's office that you pass on your way to mine and she's pretty good. This already happens with urgent care centers, but when people figure out that they're paying double to have their kid checked by a doc in a box and then come see us the next day or two for followup when they could have/should have just waited until the next morning and visited us once. But this is America and I want to be seen now! Even if it's by someone I don't know and don't trust and now that I'm here I'm wondering if this is the right thing to do and I think I'll go see my doctor tomorrow anyway. Enough on that. That's not the future, that's the present.

For patients with jobs and some money, those not on welfare, it would be a requirement to have a major medical policy to cover catastrophic illnesses/accidents so you don't go bankrupt paying for this problem. This should be pretty cheap compared to what most insurers charge for 'full coverage' currently. Flexible spending accounts or health savings accounts could provide the cushion for the 'regular' stuff like checkups and ear infections and the occasional stitches, etc., and you'd still save money. I've told people this for a long time. I even said it several paragraphs ago. But to do this we would, doctors and patients alike, have to change. Quite a bit. But it's amazing how money is a catalyst for change. Many things we have now would decrease or go away. It might go back to where only the rich and famous could have cosmetic surgery. Where only professional athletes had their knees MRI'd 'just in case'. Psychotherapy would be the domain of the rich and famous (maybe the ones who didn't get their cosmetic surgeries, or maybe the ones that did). We would observe mild viral infections and see how our child fared, seeking care only if things were not progressing normally. We wouldn't screen our 2 year old boy for autism because he isn't talking yet even though the reason he won't talk is that he doesn't have to because you do everything for him and talking would just complicate life. We might go back to the 'old days' where an illness was allowed to 'run its course' and we'd all seen one do it and the kid survived even an ear infection without an antibiotic and an antihistamine/decongestant and alternating tylenol and motrin every 3 hours to make sure he doesn't have a fever even though the fever is what God gave us to help fight the stinking infection to start with...I digress. Again.

OK, enough about how wonderful life would be if people had to pay for their own oil changes and fillups. How only major crashes would involve insurance companies and capitalism would reshape the healthcare industry. What about the poor? Those zillions of uninsured or underinsured? 

Well, for starters, in today's world, if we adopted my 'car insurance' plan above, we'd all be considered underinsured. 

But for the truly poor, one of a couple of things would happen. What would likely happen is that the state would pay the premium for this 'major medical' policy and there would be state clinics and hospitals contracted to care for the incidentals like checkups and earaches and stitches and those contracted providers would be paid a lump sum by the state to care for those for whom they are responsible. This payment would likely not be very much. It isn't now. That's why it's hard to find doctors willing to care for patients on state insurance. There's no good answer here, and the idea of healthcare as a 'right' has to be defined. How much? How soon? How good? Depending on the income qualification for the state insurance, one could envision a plan where the only difference one would experience would be at the hospital level, where a state hospital would go back to the status of a teaching hospital maybe with either altruistic doctors who love to teach and care for people regardless of their ability to pay or doctors willing to work for less because they can't make it in the 'real world', or they're honing their skills to make it 'out'. At the outpatient level, this population could pick their healthcare provider like everyone else and use a health savings plan or plain old cash and shop for 'the best for less'. 

The other scenario would be that doctors would care for the people unable to pay along with those who are able to pay, and either charge them reduced fees on a sliding scale, or be really Christian and just see them for free. If everybody (docs, I mean) had a few of these patients, it wouldn't be so burdensome. 

But none of this is going to happen, because of American politics and expectations. We're all going to be forced to pay more for healthcare, whether we need it or not, and the government is going to dictate the prices and who gets what tests and really it's not going to be a whole lot different from the sorry state it's in now where people want prime beef steaks for Denny's prices and are upset when they get a bill for the difference. I don't see it going to a Canadian system or a British system where if they run out of money before they run out of year, all the surgeries and tests scheduled get put off until the new year begins, unless you die before that in which case, they're sorry but someone gets moved up on the list. We have too much invested in our healthcare economy to dismantle it completely to go to the Canadian system, where I've heard there's maybe one or two MRI machines in the country and there's not a 'heart hospital' where you just check in and get your stents placed because of your 'cardiac screening' results the day before. There will be a 'concierge' level of healthcare pretty much regardless of how the elections go and what he or she does to Medicare and Medicaid and what the FDA does to streamline drugs into the system and whether third party payors will continue being more and more restrictive on where they'll spend your money. They may try to put everyone on a 'diet' of less fancy stuff, but I bet, given the lobby power of the pharmaceutical companies and big business medicine, they will continue to treat healthcare as an inalienable right whether you need it or not, but they'll try to ratchet down the cost by just paying less for it, and the doctor is supposed to sit still and be happy he still has a job. That's when the quality will go down, even further than it has, and medicine will be a job and not a calling for most people, and docs will just leave at 4:30 because their shift is over and they don't feel any accountability to the patient because they're just a government employee in a white coat. And then, like some who choose to pay for private education for their children even though they still have to pay their 'fair' share of the tax for the public school, people will be willing to pay for a level of care that stands out from the government clinic or hospital and is not as accountable to the government but is instead accountable to the patient. It's a slippery slope, and it's been slipping since the concept of HMO was born. Can you imagine a CMO - car maintenance organization? Where you are told where to take your car for gas and oil changes and who can work on it and how often it can be worked on and you get in line for a transmission overhaul or a new set of spark plugs because there's a waiting list and the mechanics get paid by the number of cars under their contract and not by the number of cars they actually work on? And we ate it up when Hillary made it the topic of her first 'presidency'.

OK, I'm through, sorry for the rambling. 

an inconvenient truth?

For a while now it's been getting worse. Parents asking about immunizations, are they necessary, what diseases are they preventing, how effective are they, and #1 on the hit parade - what's my opinion on immunizations and autism? Anyone who knows me knows that my opinions are usually pretty wordy to say the least, so I'm going to have to come up with a concise statement on this subject in general and this question in particular. It's not going to be easy, but I'm going to try to "flesh it out" here on the blog and compile my thoughts and put them into manageable piles.

Al Gore gets credit or crap for a lot of stuff, but he certainly is the poster child for global warming. And global warming is a good example of the effect of media/internet hype on a controversial topic. A subject where both sides have impressive information and both can wow you with their glitz and glamorous proponents. Admittedly, the vaccine controversy doesn't have quite the red carpet support as global warming but lately Jenny McCarthy has been one of the more visible celebrity faces of the vaccine/autism question, and Doug Flutie before her was one of the first, though since he appealed to guys, his effect was not as profound. In our media saturated and influenced culture, science takes a back seat to celebrity. "Don't confuse me with the facts" is a phrase I hear (and use) often. Gut feeling and quasi common sense have replaced data and expert opinion. I'm not immune to this, as I've alluded to above.

It has been said that the louder and longer one says something the more people will believe it's true. Especially if the ones saying it are pretty, famous, pretty famous, or wealthy (that never hurts).  Take evolution as an example. You might think, evolution? That's a done deal, right? We learned it in school, it is understood that it is true, except by some wacky fringe element. Well, go back 150 years and that's not the case. Even 100 years. Evolution was the global warming of the early 20th century, and Charles Darwin was Al Gore. Or something like that. Consider, if you believe in biblical Creation, by God, in 6 days or 6 million years, or if you believe in intelligent design even, the "lite" version of Creation, you are bombarded by conflicting information daily, even hourly, and you even may fall prey to this at times. I use "survival of the fittest" as a metaphor quite often, and "natural selection" rolls off my tongue like any other solid method of reasoning out some line of thinking. We are creatures of our culture, and like it or not, it influences us at many levels.

So, we buy a hybrid to decrease our "carbon footprint" despite the people who tell us that the factories that make the batteries that make our cars "green"  are emitting more pollutants than the semi that just passed you on the highway. Tradeoffs are a given in our world.

Unfortunately, the question of vaccines affects children, and that means it affects me. Global warming means I bought a Prius and had less guilt. Giving vaccines with the possibility that they cause autism or other problems is a difficult thing. Not giving vaccines with the possibility that the diseases prevented will reoccur and cause untold agony? A less likely evil? As long as most people still vaccinate their kids? The concept of "herd" immunity. Where it is said that if most of the "herd" is immune to a particular disease, the rest benefits from this protection.

So...global warming, evolution, vaccines cause autism. Which is true? Which is just media hype? Are these questions with absolute answers of yes or no? In the case of evolution, I am a strong believer in Creation by God in however long He decided to take to do it, He says 6 days and a day off on the 7th, so I'm going with that. Slam dunk yes. Global warming? Vaccines? I'm less certain that there is a black "yes" and a white "no" on either topic. Unfortunately, most of the "easy" yes and no questions have been settled - not always the same for everyone, but they're settled in the minds of the people. Are we affecting our environment with carbon fuels and pollution? But does the good outweigh the bad? Does the ability to travel by car or plane make our lives easier and is the tradeoff worth it? Is technology worth it? Are we giving our kids chances that previous generations didn't have by vaccinating against killer diseases? Are we causing problems that are worse by preventing unlikely but deadly infections? There are few people still alive who have experienced polio firsthand,  but even someone my age, in medicine, remembers Hemophilus influenza, type B. The ten or more days in the hospital on IV antibiotics. The great possibility of deafness if the child survived. 

Suffice it to say, this generation has not suffered the effects of the infectious diseases endured by the previous ages. The proponents of vaccines can show graphs of the prevalence of a disease and the controversy over vaccine and the inverse relationship between the two - i.e., if the disease is common, there is little controversy over the vaccination, and if the disease is seen as historical, the vaccine side effects become the subject of controversy, not the disease. Though I don't want to see it, if a measles outbreak occurs, the whole autism/MMR vaccine issue will be a moot point for a while. But we do need to revisit the issue of vaccines and side effects and whether the good outweighs the bad. There are few people without obvious agendas who are taking sides on this question. That is a huge problem - those with personal involvement weigh in on their particular side and then facts take a back seat to emotion, or at least "spun" facts. Statistics can be "spun" to make anyone's point.

Are we causing harm to our children by immunizing them against diseases that most people have never seen? 

To those who are totally in favor of vaccines, for all diseases, in every kid, at any time, the picture portrayed is of a world where the diseases prevented by immunization are lurking just outside the door, waiting for us to let our guard down and let them back in to kill and maim our beloved children in minutes.

To those who believe that vaccines have caused more problems than solutions, the picture is a world where things would be fine if doctors and vaccines and medicines didn't exist and if people would just eat right and exercise, things would be fine.

OK - neither one is right, which takes me back to the earlier comment about no "black and white" answer.

I find myself sitting on the fence. In terms of diseases, I've experienced HIB meningitis personally and professionally. When I say that the worry caused by a phone call about a child with a fever is much less now that it was 20 years ago, it is an understatement. To say the least. I have put the early years of practice behind me. When, after a 2 A.M. phone call about a child with a fever, my wife would say "do you think it could be meningitis?". And I couldn't sleep after that. That's pretty much gone. As gone as something that used to happen but hasn't happened in a long time can be gone. I wouldn't wish it back in a million years.

So...some doctor can say the same about diphtheria, tetanus, polio, measles, etc. 

We are a society of convenience. We vaccinate against chickenpox because it costs the mother a week off of work and that costs a lot. Of course, there is the justification of MRSA and the secondary infection of the chickenpox lesions that could cause worse problems than just the itchy rash. We would like to see rotavirus disappear. My first rotavirus experience was a funny episode in my first year of med school where my roommate got it and couldn't decide whether to sit on the toilet and throw up in the bathtub or sit on the tub to evacuate his bowels there and vomit in the toilet. It was a one or two day thing. And still is for most kids. But it can mean hospitalization and for God's sake, that's an inconvenience to say the least. Kids in Africa die of rotavirus, but here in the US of A, that shouldn't happen. So we immunize to save lives and to save jobs and lifestyles. Where do we draw the line? 

Reading history, I find that smallpox may have been the deciding factor in the conquering of the New World. We have been taught that it was guns or education or desire or something purposeful or controllable that helped Europe conquer the Americas, but as I read history, it was smallpox. Or some other infectious disease/s. 

So...I'm in favor of immunization. I can be tolerant of parents wanting to spread out the vaccines over a longer period of time, while laughing at the fact that the multiple ingredient vaccines that today's parents are scared of were created to meet consumer demand from 15-20 years ago. 

We; doctors, scientists, researchers, should review the data, devoid of emotion and secondary gain, and come up with a reasonable approach to achieve the necessary coverage for children for diseases that are still present and active, and propose this with acquiescence to those opposed, and win them over with our data and dry information and not with bullying and laws and requirements.

And those who are opposed should look beyond their own personal experience to the big picture and the possibility that they were the victims of cruel fate or divine providence,  or maybe to the power of the almighty dollar and the whims of drug companies.

No one is right. No one is wrong. It's not clear, at least in my mind, like the evolution controversy is clear. God created this world.

But we should begin to face the problem of vaccines and autism with the idea that both sides have reasonable, defensible ideas and data. That there is no one right answer to the question. That both sides together, with cooperation and collaboration, may come up with a safe and effective plan. However, until both sides can discuss the issue without emotion and personal baggage, without millions of dollars helping to decide the outcome, this seems an unlikely dream.

I want to place myself squarely in the middle of this controversy. I see the need, and I see the concern. I'm not smart enough to know everything about everything. I will continue to encourage complete vaccination for every child while respecting the decisions of those parents who do not want to immunize or who want to delay or spread out vaccination. It's uncomfortable up here on the fence.