So our fearless health care leader, the guy with the worm in his brain, is going around saying that we should let bird flu run rampant, run its course, kill the susceptible chickens and that way we’ll be left with a national chicken flock that is resistant to bird flu.  Is this crazy?  Or does it make sense?​​​​

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Get out the earplugs and blindfolds, Susie, they are at it again.

 

Brothers and sisters, get ready for another round of yelling about Medicaid, which will be all heat and no light.  As some of us know, the mean Republicans have committed themselves to cut $880 billion out of the federal budget over the next ten years (so they can fund tax relief for the rich, some say), and all the experts among the dumb Democrats have decided that they will be cutting Medicaid.  Or Medicare.  Or both, because only those two programs have that kind of money in them.

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So it’s hospital gala time again. You know the drill. Fancy invitation. Black tie optional event. A thousand people in a convention center or hotel ballroom. A high-powered committee on the invite, most of whom have nothing to do with planning the event itself, and sometimes bold-faced names who serve as honorary chairs, whatever that means. Adequate food.  Too many self-congratulatory speeches.  Music that varies from okay to not. (When I went to these twenty years ago out of loyalty because I was on the medical executive committee of a few of these hospitals, I got to see a friend who is a very good jazz pianist, and we’d hang out between sets.  The only interesting part, for me.) 

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So we’ve had regime change, and the new party line is that Covid was a lab accident.  The CIA, which may or may not have anybody working there by the time this is published, now says they think the Covid was caused by a lab leak — but that is a “low confidence” determination,  which is bureaucratic-speak for, we don’t know either but people will fire us if we don’t say what they want so we are saying it.

 

All this is crazy because we don’t know and will never know whether Covid evolved naturally in animals and spread to humans, or whether it was created by a lab in Wuhan that was engaged in gain-of-function research.

 

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I’ve now tried twice to make an appointment for a colonoscopy with a gastroenterologist.  I also had to call Blue Cross, got put on hold after having to enter a zillion numbers and pressing 2 for this and three for that, and then 25 minutes later got called back by a nice young human!  These are the kind of experiences we have all become accustomed to after years of managed care and health care bureaucracy.

 

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Full disclosure: I hate United Health Care, and have hated them for thirty-five years, since they bought out Ocean State Physicians Health Plan and became the second largest health insurer in Rhode Island, in the late 1980s. I think they are predatory and manipulative, and leverage market power inappropriately in pursuit of profit, making a critical public health process into a profit-making engine in a way that hurts us all. Years ago, when I was in practice, I begged my partners to drop United, because they were costing us money and time that we didn’t have to waste.

 

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So there’s talk that Robert F. Kennedy Jr will defund the NIH.  Or something like that.  In full disclosure, I am not a fan of the man.  But, I also view the hysteria of academics and institutionalists about his nomination to head HHS with a somewhat jaundiced eye.

 

The National Institutes of Health is the nation’s – and world’s – premier health and disease research institute.  The NIH has been around in some form since 1887 and is the branch of the federal government responsible for biomedical research.  It has an annual budget of $47 billion dollars, of which about $30 billion is spent on grants to researchers at colleges and universities across the nation and the world.  (For context, the US as a nation spends less than $165 Billion a year on primary care.  $47 billion would fund primary care for 94 million people.  There are 27 million Americans without health insurance in the US in 2024, so the NIH budget could pay for providing primary care to those who lack access to it three times over.)

 

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Okay.  We think women need mammograms if we are going to reduce the number of women dying from breast cancer.  (Men also get breast cancer.  It’s less common.  But it happens.  There is no mammography recommendation for men, however.) We think everyone of a certain age needs screening for colon cancer, which is or sometimes leads to colonoscopy, if we are going to reduce the number of people dying from colon cancer. 

 

But there is some real craziness that happens to women at mammography time. And to many people, at colonoscopy time.

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So we may or may not have a guy with a worm in his brain running CDC or HHS. Time will tell. But it is clear that, for the moment, we have a guy with a famous last name who appears to be a vaccine skeptic, and who has the ear of the President-elect.

 

What’s up with that? Vaccines prevent childhood diseases. Shouldn’t they be as American as apple pie?

 

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Lifespan, which is about to be rebranded as Brown University Health, just bought St. Anne’s Hospital in Fall River and Morton Hospital in Taunton, Massachusetts for $175 million, making it a two-state hospital system.  Should Rhode Islanders care?

 

 

On the face of it, it’s no big deal.  A number of Rhode Island hospitals – Landmark in Woonsocket, Westerly Hospital, and CharterCare (Roger Williams and  St Joseph’s  Hospitals) have been owned by out of state entities for a long time, and the sky hasn’t fallen  in, although lots of people wonder about the financial stability of CharterCare and the extent to which it may have been drained by the private equity process.  But a Rhode Island hospital system owning an out-of-state hospital or hospitals is a relatively new phenomenon. (Lifespan attempted a merger with Tufts University Hospital about twenty-two years ago, though it wasn’t clear who was acquiring whom, or what the purpose of that short-lived affiliation was at the end of the day.)

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So there are now a number of programs and great organizations that buy up and retire medical debt.  Which is kind of a cool idea.

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It turns out that 20 million Americans, or 15 percent of American households, have some  medical debt over $250, that Americans owe at least $220 billion to health care clinicians and organizations. 14 million people owe more than $1000, and about 3 million people owe more than $10,000.  Not surprisingly, people in worse health, people living with disabilities, lower income people and people without health insurance are most likely to have medical debt, adding insult to the injury of poverty, poor health and being disabled.  About two thirds of all personal bankruptcy is caused by medical debt – causing about 530,000 bankruptcies a year in the US. 

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Before I start talking about the current presidential campaign, I thought I’d disclose my biases.   I’m an independent with complicated political views: fiscally conservative, small government oriented, socially progressive but not woke.  I don’t love our choice this year, which seems to me to be the choice between Julius Adolph PT Trump and Tweedle Dum and Tweedle Dee – the current VP seems smart and capable but is running a weak-wristed campaign in which she isn’t really saying much beyond don’t vote for the other guy.

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Basically, everything is crazy, for the caretakers of people living with dementia. If you have dementia, it’s hard for you, because you can sense what you don’t know or understand, and sometimes see the apprehension and disappointment in the eyes of the people you love, and feel that but too often don’t understand it, which is part of the cruelty of dementia itself.​

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​Hospitals pulled the support of primary care doctors and chased us out of the hospital. They replaced us with hospitalists, who took turns being a patient’s doctor. Sometimes they switched every week. Sometimes every two weeks. Sometimes once a month. But sometimes every few days, so if you are in the hospital, the person taking care of you is now someone you’ve never met, and who isn’t likely to know you or your family.​

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Basically, everything is crazy, for the caretakers of people living with dementia. If you have dementia, it’s hard for you, because you can sense what you don’t know or understand, and sometimes see the apprehension and disappointment in the eyes of the people you love, and feel that but too often don’t understand it, which is part of the cruelty of dementia itself.  

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First some good news!  The Rhode Island General Assembly passed two bills and created one study commission that helps us start getting better access to primary care in Rhode Island.

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The whole thing is crazy.  And expensive.  And sad. 

 

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But we have met the enemy, and they are us.

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​Eye ointment?  Yes, eye ointment.  You see, in late April, CDC announced there is a shortage of erythromycin eye ointment, which turns out to be a big deal.  What?  Isn’t erythromycin one of the oldest antibiotics that exist?  Aren’t here a hundred or a thousand other eye ointments?  Who cares about one old medicine?

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I’m not sure where I stand on letting pharmacists bill insurance directly.  On the one hand, pharmacists are critical and valued members of the primary care team and provide services that greatly benefit patients.  On the other hand, fee-for-service billing, billing a patient or their insurance company every time a clinician of one stripe or another sees a patient, is part of what has destroyed primary care itself, and should be shown the door as soon as possible.   So letting pharmacists bill fee-for-service doesn’t sound like it will fix anything.

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What the heck is going on?

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What the heck is going on is this: health care has been taken over by bureaucrats, administrators, and lawyers, who know only how to protect (and some would say enrich) themselves and their organizations, people who don’t know anything at all about medicine, but feel embolden to make decisions that cost patients’ lives.

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Breaking news tells us that pharmacy professionals at two CVS corporate retail stores in Rhode Island, in Wakefield and in Westerly, want to join The Pharmacy Guild, a trade union that represents pharmacists ands pharmacy technicians, joining their colleagues from around the country who are engaging in similar union activities at CVS and Walgreens Boots Alliance – and other companies as well.  Emergency room physicians, anesthesiologists, and medical residents are unionizing -- and striking -- as well.

 

What’s going on here?

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And there, in a nutshell, is what’s crazy in health care today.  Health care is filled with ethical motivated people, who want to help people, but also want a decent life and a reasonable income.  But then there are all sorts of folks with MBAs and money to spend, who want to buy up or buy out the people who care, push up the cost, and make money for themselves out of the deal. 

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A friend in her sixties called to ask if she should take the new RSV vaccine, which is being heavily promoted to people over sixty.  That it is being so heavily promoted is driving me a little crazy.  

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We can improve the public’s health in the US and do so affordably. And eliminate Hepatitis C, HIV and colon cancer.  We just need a health care system that provides primary care to all Americans, in every American neighborhood and community.

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It’s crazy we haven’t provided primary care to all Americans.  And it’s crazy to read plans like Dr Collin’s, which talk about only one disease and don’t focus on what we can and should do together as a nation, which is to provide primary care to all.

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Now think of all those forms. The back-to-school notes, which schools require because they don’t trust parents to be truthful; the 11-page Medicare Home Health Certification and Plan of Care form required for people getting home health, which must be filled out every two months. Eleven pages. No one understands it, not the doctors who fill it out, and not the home health nurses whose computers fill out most of it. I doubt anyone at Medicare understands it. There’s a form to help poor people from getting their electric or gas service turned off in winter and there are workers’ comp forms. 

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Why is it so essential to have a family doctor physician you trust? The answer is straightforward. Everyone needs a healthcare advocate who knows them, their family and their community, who understands healthcare and medicine, and can guide you when you’re sick and help you prevent avoidable diseases and early death when you are well. In a world filled with confusing medical information and profit-driven interests, having someone you can rely on to provide honest advice is crucial.

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During the pandemic, it wasn’t possible to know how states and nations compared regarding their management of the pandemic, because the disease spread in surges.  A state or nation that was doing well this week might be doing poorly the next.  The question always was, which place would have the lowest case fatality rate at the end of the pandemic — the lowest number of deaths per capita — after most people had become immune and pandemic spread stopped.  It was possible that our short-term strategies, like masking or social distancing, might have produced short-term benefits but no long-term mortality advantages.  Technically possible.  I wanted to wait until the end of the pandemic to see, because it is scientifically important to keep an open mind.

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What does Flonase cost? $16 at Target.  $15 at Walgreens. $26 at CVS but for twice as many sprays.  But there is a generic that costs $9.69 at Target and $9.18 at Walmart and $20 at Walgreens.  I pushed hard and found five bottles for $25 or about $5 a bottle on Amazon and each bottle has 144 sprays, or twice as many as most other generics.  Which means it likely costs $1 to $2 to make.  (Interestingly, it costs $40 in Canada, where it is still prescription, so thank you FDA for doing at least one thing right and making it generic here.)

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The Mayo Clinic has hospitals in Rochester, Minnesota; Phoenix and Scottsdale, Arizona; Jacksonville, Florida; Abu Dahbi; and an outpatient clinic presence in dozens of locations across a number of different states and countries, including London. 

 

 

It’s a “non-profit organization committed to clinical practice, education and research.” It has $16.3 billion in revenue, $15.7 billion in expenses with an operating income – what would be called profit if it was a for-profit — of $595 million in 2022.  The budget for the State of Rhode Island, for 1 million people, was $15.1 Billion in 2022. The Minnesota budget for 2022 was $60 billion, for 5.7 million people, by comparison. 

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In the United States, we have a health care market, not a health care system that provides the same set of essential services to all Americans.  We’ve all gotten used to that – it makes for health care that is confusing and impersonal.  But most of us can’t figure out how to change it, so we suck it up and take what is dished out, and are grateful that emergency rooms exist to pick up the slack, so that most of us don’t die from trivial injuries or dread diseases, most of the time.  

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