Refuse to Fuse or You shall Re-Fuse

I have always told the following to my patients who were contemplating a radical procedure like a spinal fusion for example. Even the beest surgeon out there can only control one third of the variables related to your procedure, i.e. everything related to good technique and surgical outcome. There are two other thirds that nobody tells you about: one third of the variables has to do with your body response to these foreign objects placed in your back, the amount of scar tissue, rejection, etc.; and the last one third i has to do with what the future has in store for you, are you going to have another fall, MVA, injury, how soon? It could happen as you walk out of the hospital and boom you entire surgery is jeopardized. So in the best of all worlds, your surgeon has only control of 33% of the odds regarding the outcome of that fusion, regardless of how skilled he really is. That does not means that the remaining odds will all be against the patient but would anybody want to take these odds lightly?

The other thing about spinal fusion, is the infamous domino effect. There are indeed 24 vertebrae and 23 discs from the occiput down to the sacrum and they are all designed to work in unison to enable us to bend forward or backward, rotate and move side-to-side. Any time one level is fused its burden will have to be born by the adjacent levels hence the following domino effect: any time a disc is fused the adjacent levels have to pick up the slack and start deteriorating faster until they soon need fusion themselves. The peak age of back and neck injuries is  35 to 45, the height of work productivity. If a fusion is started at that age, every 3-5 years the patient will need another one, following the domino effect. Here goes work productivity and here comes Social Security Disability. About 40% of people on SSDI have "failed" back surgeries.

Many more of these procedures are performed in the US as compared to Western Europe and exponentially more than the rest of the world, largely because secondary gains and healthcare systemwide profits: surgeons, hospitals, radiologists, device manufacturers, lawyers, etc. I knew a lawyer once who told his client my patient once: "If you do not get this neck fusion, you will not have a case". It literally was not his neck on the line so he had nothing to lose. This sort of arm twisting is done routinely: lawyers pushing their clients to go under the knife, whether they need it or not, for their own monetary gain.

The truth is that even the best $3000 titanium screw (that costs $275 to make) cannot heal like a human vertebra or disc can. The minute this screw is in, that patient's anatomy is changed forever. If we believe the obvious premise that one's own God-given anatomy is best and better than any human remodeled one, changing this anatomy irreversibly and irreparably in your 4th or 5th decade can only spell trouble, especially in an era where people reach their 10th decade routinely. If that screw moves or breaks or gets bent because of a subsequent injury, or becomes the seed of a systemic infection, it will NOT heal, it will just have to be replaced by spare parts in another surgery and so on and so forth.

My longest patient (25 years) is a textbook illustration of what a fusion nightmare can be. I saw her first in her early 30s and she already had a couple of whiplash injuries in auto accidents and her neck looked like 45. We tried everything conservative but nothing worked and minimally invasive procedures were not very fashionable at the time. So I referred her to one of the best neck surgeon's in Manhattan whom I knew personally for scrubbing with him. Neck fusion was performed on two levels and went well except...a few months later one level did not fuse despite the rigid bracing and all that (second third of odds her body's response). Here she went for another fusion of that same level. A year or two later she had another MVA and she ended up requiring a third cervical level fusion (third third of odds: you do not know what the future will bring). She went on like that between new accidents and new fusions and now she is fused from the back and the front from C3 to C7 (the entire neck practically) and she is barely 54 years old!  I am skipping all the pain procedures, medications and tests she required over these years and how it all affected her life greatly as you can imagine.

I will end this blog on a sweet and sour note. One of the first joke my orthopedic attending told me when I started training in this country at a Yale hospital goes like this: If you have 5 orthopods in a room how many advices do you get about a case? 6 because by the time you ask the fifth, the first one you asked has changed his mind!

So the morale of this story is: Go for a second, third, fourth opinion...keep going till somebody tells you you do not need the fusion and go with that one.

A Problem for Every Solution

The 1989 Sioux City plane crash caused 112 deaths but 184 survived! How often do we have survivors in a jetliner crash? One would expect these survivors to become religious zealots and to avidly buy lottery tickets. Instead there were more lawsuits filed by survivors than by the families of the dead. Go figure. Surviving a horrific plane crash is a pretty decent solution by itself and should leave the survivor eternally grateful to their maker, yet the plaintiff lawyers would not hesitate to fashion it into a legal problem that would generate cash instead of blessings. I often wondered how much of that cash was donated by the survivors to a charity or church of their choice, or how much of it went into plane crash prevention. The tragedy of 9/11 is a similar example where a horrific event becomes a kitty bank for the survivors.

I was highjacked flying on China Air from Beijing to Shanghai in December 1991, and ended up in Fukuoka Japan with 17 other  americans. A lot of delays and disruptions but no injuries. I wonder it I had a case. I did have a couple of nightmares come to think of it. I guess it is too late now. At Fukuoka airport, after we were released, we were literally mobbed by the Japanese paparazzi, with all their Sony and Toshiba equipment clicking and flashing at us. Before I was pushed into a cab, I saw across the car top a tall dirty blonde american-looking woman. She said she was from NBC and asked me: "Any violence? anybody got hurt?". When I said I did not think so, she swiftly walked away with disdain in her step. I robbed her from her story I guess.

Let us now take a look at the Japanese tsunami of 2011. Very scary and devastating event that drags on and on, causing a meltdown in the Fukushima nuclear plant among other catastrophes . The people banded together, with no complaints to speak of, and went about the task of rebuilding their country as soon as humanly possible. They did that religiously after each and every earthquake and after WWII, Hiroshima and Nagasaki. The Asian culture heightens and glorifies personal responsibility. It  is singularly focused on solving problems versus pointing fingers on who dunnit. The former action is a lot more complicated and requires consensus, time and hard work; the latter is a quick fix and gives the public pounds of flesh to appease it, embellished by media sensationalism and the works.

The "quick fix" culture is pervasive in our very government with its sidekick "kick the can down the line". This is why we are having such a difficult problem resolving long-term problems such as taxes, healthcare, entitlements, immigration, national debt, etc.

Prevention works and it is the perfect solution yet it is incomprehensibly mired in problems in this country and most western countries: First and foremost, it threatens the business of big pharma, big hospitals, big health insurers and a large herd of various providers. How can we consume it? how can you pay and reimburse for it? If it starts working lots of people will have to start packing as they became obsolete. Second, it is not a quick fix and it requires daily hard work and focus. You cannot get it in a bottle or by pressing a button. You actually have to WORK at it. Bummer!

On this note, I will leave you with a quote from Albert Einstein: “We cannot solve our problems with the same thinking we had in creating them”. He is said to have defined "insanity as repeating the same behavior and expecting different results"

Prevention Takes a Bite out of Life but Responsibility is the Teeth

America is a country of consumers who fancy quick fixes and immediate gratification. Much more so nowadays then during the agricultural era whereby one had to put in the hard work to farm the land daily with the hope to harvest a decent crop some day in the future, weather permitting. These are empowered consumers able to access a whole host of things and perform a whole host of tasks just by sitting in front of a computer, or even a cell phone for that matter. The incentives for real manual work are all but gone and with them any chance at true prevention thru physical exercise.

Healthcare can be "consumed" thus fitting the profile described above, but NOT prevention. The latter advocates anti-consumption: How to stay well and fit so as not to have to consume medications or healthcare services. Nonetheless prevention can be squeezed into a consumer's mode american-style via a plethora of supplements, vitamins,  and nutraceuticals and a litany of exercise modalities: aerobics, yoga, pilates, spinning, bar method, etc. Those industries are booming now because, albeit preventive in nature,  they finally found their path to the american consumer.

Germain to this concept is to have those consumers PAY for their own preventive products and services, thus demonstrating a level of responsibility that is essential for the prevention seed to grow. If those were covered by insurance,  personal responsibility would be gone and with it prevention. Carriers will not pay for it because there is no know code for Prevention in the CPT code book, and it is just as well I think.

This equation is quite simple yet it is often adulterated by ill-conceived regulations and legal processes. Examples abound: Take the tobacco issue for example, just as we were making headway in legally eliminating the threat, recently many states are legalizing marijuana which is six times more toxic. Of course little if any of the tobacco settlement money awarded made it into management, prevention and care of tobacco-related health ailments. Taxes increased significantly on tobacco and I doubt that any of that money is being used for treatment and prevention of these ailments.

Tobacco, Asbestos and others like 9/11, Sandy, Irene, Katrina became great causes célèbres for huge class action suits and even huger settlements, but most of the money collected rarely reaches target and very little if any goes to PREVENTION.

Prevention without responsibility WILL NOT work: If Mayor Bloombeg bans the 16 oz soda bottles, the consumer will buy two instead, and so on and so forth. Another less publicized example is Infection prevention. Enormous focus is placed on hospitals and surgical centers for infection control with interminable regulations but the truth is hospitals still have the worst infection rates (MRSA, mutant bacterias, etc.). With regard to ambulatory surgical centers (ASCs), the patients spend very little time there (a couple of hours on average) so logically the odds of on-site contamination should be minimal. Infections do occur after ASC surgeries sometimes 1-2 weeks later but I submit to you that they are caused by and large by the patient's poor habitus and nutrition, lacking hygiene and unsanitary environment and care-takers, so what if anything is being done for THAT prevention? Nothing really. ALL the emphasis is placed on the very short time patients spend in the ASC, a couple of hours versus the days they are at home or elsewhere in post-op.  Why? because it is a lot more feasible, albeit futile, to regulate a licensed medical practice/ASC than a patient's home environment and habitus. Unfortunately the regulatory bodies CANNOT regulate personal responsibility; that is why they usually fail at prevention.

That does frustrate them so they come out with more regulations which is the only thing they can do. Still burying the providers with regulations will NOT breed patient personal responsibility. The lack thereof is pervasive amongst patients and the regulators cannot do anything about it: no show for follow-up care, not taking prescribed medications, not following post-op instructions, lying about their medical history, about their meds, and so on and so forth. Then a complication may happen and it certainly will be somebody else's fault, i.e. the provider of course: "my lawyer said so!"

The American consumer society is duly focused on finding out who is responsible and IT MOST CERTAINLY CANNOT BE ME! Nevermind fixing the problem let us just find out who to sue instead (usually Mr Deepest Pockets). Isn't it the American way?

Prevention is becoming more and more consumable (Wellness will soon be a trillion dollar industry) so it may have a flying chance in the USA after all, especially in these days of increased longevity, costly and troubled healthcare system and poor economy. Give it a good dose of personal responsibility and you got it made.

When it comes to your health, Defense is surely the best Offense!

Pay the Patient Says the Carrier, He is the Customer NOT the Doctor

Insurance Carriers give countless daily hassles to physicians in private practice regarding payment of their services. Of course there is the habitual deductible/co-pay/out-of-pocket/coinsurance saga which can never be ascertained exactly. Then comes the procedure codes: this one does not need authorization this one does and that one depends. Impatiently awaiting the infamous EOB (explanation of benefits) in the mail is like expecting a lottery drawing, except that the latter is more predictable. You may get paid more often in the EOB but how much is always a surprise no matter how precise your pre-determinations and predictions, and denials are galore. To name just of few annoyances: the surgeon may get paid but not the larger facility bill or the whole bill can be rejected because one code out of many is deemed "experimental".  Bottom line, you can never be sure of whether you will get paid and how much. Try running any kind of  business effectively this way.

Appeals are suggested always but they are a joke aimed at creating more useless payment delays and wasting more of your time and staff's time. Every level of appeal takes 60 days and there are several. Unless the patient actively takes his doctor's case at heart and is appreciative of his care, the doctor does not have a prayer with the carrier, especially if he is out-of-network.

In network physicians may get paid faster and easier but the amount is usually puny and non negotiable. Out-of-network physicians suffer most of the guessing game described above. First when the carrier's plan mentions it will pay 70%. that is NOT 70% of what is billed but 70% of what they allow, which is supposably based on "usual and customary". How the latter is determined is still a mystery to me after 30 years of practice.

Perhaps the most frustrating and obnoxious action of the commercial carriers is to pay the patient DIRECTLY when the physician is out-of-network. The patient receives this large check in his name with no W9 or 1099 attached. It is like winning the lottery. Does anyone really think that this patient is going to run to the doctor's office with his check IN THIS ECONOMY and give it to him saying: "Thank you for your services".  This money is all but lost to the practice and also to the IRS since the patient has absolutely no compelling reason to declare that as income. It is as if the carrier is plotting to defraud the IRS of that money! One would think there would be laws preventing this sneaky carrier move. There maybe but nobody cares.

Slavery can be defined as working very hard while somebody else gets paid for your work. How is that different from the out-of-network physician plight?

No-fault carriers are starting to get that way too. They issue checks in both the physician's name and the patient's and now you have to wait for the latter to show up and sign his check so you can deposit it. More hassle more time wasted.

Doctors routinely get paid less than half their bill amounts up to one year later sometimes. In the interim, they provided the care, paid the nurses, clerical staff, supplies, insurance, utilities, rent and others, practically subsidized this patient's care and they have to wait patiently to get paid not knowing how much and when. As I said above, try running any kind of business effectively this way.

It is often that a physician's only recourse is lawyers to arbitrate No-Fault cases, sue commercial carriers under ERISA or sue the patients who kept their checks, If successful these suits will pay a third of what is collected (nowhere near 100%) to the lawyer, exhausting whatever profit left. Furthermore, If the lawyers are too aggressive they could provoke  retaliations in the form of malpractice actions from the patient to defray the money theft, or EUO (examination under oath) from the PIP carrier to annoy the practice and delay further payments, or others. None of that is inherent to the practice of medicine but it was taking more and more of my time and I called it survival.

If NOT Evidence-Based NOT Medically Necessary

I cannot tell you the times I had to deal with verdicts like "experimental" or "not medically necessary" from the carriers, especially when contemplating state-of-the-art minimally invasive procedures that do shorten surgery and recovery times, lessen morbidity and cut cost.

Their determination is usually based on what is published in the literature or so they say. Having published a considerable number of papers in peer-reviewed journals over the years, I can tell you that by the time an article makes it in the journal, it is at least 2 years if not longer after the idea even came to the authors. The more respected the journal and the longer the queue for publication. Thus the so-called "evidence" is usually stale by the time it is published and people can officially refer to it.

There is quite a backlog this way and it is absolutely not fair to force the patients to wait it out, or even medically sound. Indeed if the patient is in pain NOW, he will be seeking relief via more invasive and more irreversible procedures, hence more morbidity, more risks and more failures; and/or resort to an ever increasing amount of narcotics to placate the pain. So when that article is finally published, the patient may have developed a narcotic dependency (all too common) or chronic disability secondary to surgical complications or scarring, e.g. Failed Back Syndrome or both.

The devices used in these minimally invasive procedures have usually gone through the FDA process prior to hit the market and these procedures usually would cost the carriers retired or almost less money, so why the wait. The only plausible explanation is that the medical directors and consultants of these carriers are usually retired or just about and they have not been exposed to these procedures understandably so they resist them. Another explanation is been-counter driven: why pay now if we can pay later with the hope that later will never come about: patient feels better, changes his mind, dies, etc.

The “medically necessary” determination is even more appalling because it is NEVER made by clinicians who actually examined the patient, listened to him or delved into his case. It is made by case managers, adjusters, so-called peer-reviewers and other bureaucrats, all located way off-site. Sometimes the surgeon and the anesthesiologist get paid, implying the procedure must have been deemed necessary, but the facility (largest bill) does not get paid, probably implying the procedure should have been performed on the street or some other similar place! No rime or reason and no accountability!

There has been a clear shift towards Alternative Medicine and an increased demand for such by the population, especially Acupuncture. The latter has been practiced primarily in China for over 5,000 years and often is used exclusively for a variety of ailments. No western-style evidence-based publications to my knowledge and yet the Chinese population is obviously doing well and still growing. Draw your own conclusions!

When I underwent acupuncture training in 2001, I could not find any carrier to pay for it so I asked patients for modest cash payments here and there. Now they are starting to pay better not because there is more evidence-based publications but because they finally realized it is CHEAPER with no side-effects or morbidity to speak of. With almost 5,000 years of non-evidence-based experience (meaning no double-blind placebo studies to speak of) with this technique, at least the health insurers are not still trying to call it experimental to avoid payment.

Whether the carriers agree or not, Medicine is an Art not just a Science, and time-honored techniques like acupuncture do prove it so. Many leaps in medicine occurred during experimental processes and to deny that is to deny progress itself. Look at Viagra for example: It was being tested for blood pressure control and…the rest is History!

Ménage à Quatre: Doctor-Carrier-Lawyer-Patient

In this chapter, the 1969 Peter Mazursky movie Bob & Carole & Ted & Alice is vivid in my mind. As Dr. Bob tries to develop a "professional" relationship with patient Alice, Carrier nurse Carole and lawyer Ted are running all sorts of interference to prevent that to happen. If Sigmund Freud was still around he will probably tell you that Dr Bob's mother and patient Alice's father maybe joining them too in that bed.

The straight-forward time-honored patient-doctor relationship has been long replaced by some Mazurskian or Freudian scheme that curtails and dilutes any possible interaction between the doctor and his patient. Often the quartet described above is replaced by a quintet or a sextet, including adjusters, nurse case managers, independent medical examiners, and so on and so forth. A number of characters have wedged themselves between Dr Bob and his patient Alice over the years and that number is growing.

First to suffer when that happens is the respect of the medical profession. The more Dr Bob's medical authority and proposed treatment are undermined and second-guessed by a variety of middlemen/ women, the less compelled patient Alice is to trust him, follow his advice and direction, appreciate his care and be loyal to him. Dr Bob has to deal with this frustrating fact as he also has to deal with nurse Carole, lawyer Ted and all the others. The result is less time to devote to patient Alice, less drive to heal, thus even less respect and more disengagement of patient Alice.

The underpinning of this Ménage à Quatre, à Cinq ou à Six is money: who is footing the bill for this physician encounter? This reminds me of a wall sign I saw in Piccadilly Circus during my first trip to London in 1973: "HE WHO HAS THE GOLD MAKES THE RULES" and boy he lets you know it and feel it. As long as patients expect some third party to pay the doctor for their visit, thus dictating all the terms of this visit, the time-honored patient-doctor relationship will soon be a thing of the past if it is not already. Patient Alice went to Dr Bob only because she was told to by her lawyer Ted or because she saw his name in nurse Carole's carrier's directory. Hence her loyalty will tend to reside with Carole and/or Ted and not Bob. Furthermore they are paying the bill!

To give you an idea of how intrusive these "middlemen" can be, two examples come to mind: One day, about a year ago, I received a phone call from a physician (he said he was)  from another state asking me why I put one of my patients on Naprelan (extended release Naprosyn, a common NSAID) and not on the generic Naprosyn. It took about 15 minutes of my precious time to explain to him why, in this particular patient, one was better than the other even though a bit more expensive. Two doctors had to joust about some basic drug and waste their time so that the carrier saves some money. One day soon I may receive a call questioning my use of St Joseph Aspirin instead of Bayer and the list can go on and on. Of course lawyers (and insurance docs) get reimbursed for phone calls per six-minute units but treating physicians never do.

Another time, my staff had requested an authorization from a carrier to perform a minimally invasive spinal procedure. A few days later a neurosurgeon (he said he was) called on behalf of the carrier asking me to describe step-by-step the procedure I was going to perform prior to approving it, especially whether I was going to visualize the nerve root or not! Needless to say that I usually try to stay clear from the nerve root. Next they will have spy cameras in the OR capturing the entire procedure then deciding what frame they may pay for and how much. Here goes Clinton's Patient Privacy Act.

It is my contention that unless the patient is paying for his/her doctor visit, s/he will not be able to select the doctor s/he wants and trust and respect this doctor, thus minimizing second-guessing, treatment delays and frivolous law suits. Doctors visits need not be expensive (sliding scales are common) and patients can receive receipts  to submit to their carriers and battle for reimbursement. Health insurance coverage should be focused primarily on catastrophic occurrences and not on run-of-the-mill doctors visits.

Eliminating the middlemen is maybe utopic because of all the different interests involved, but  it is the only way to restore the patient's sense of responsibility for his/her health under the direct guidance of his physician. Pay a flat fee for the visit and instead of wasting time and energy trying to figure out deductibles, copays, donut holes or out-of-pocket, focus that energy on getting better under your trusted doctor's guidance. This is exactly what happens in a lot of less advanced countries in the world, where the medical profession is still highly respected, and their healthcare is not all the worse.

Making a Buck by Passing the Buck

Referral is another name for this game. A doctor is never penalized or charged for over-referring. Not only it is considered good practice but also good cover your but and good business. Starting with the latter a bona fide game of Ping Pong starts between specialists whether sending the same patient back and forth or I send you one you send me one. Some hospitals who stand to gain a lot of dineros from procedures may even double the bet: you send us one we will give you two!

A classic scenario usually goes like this: primary care doc sends back patient to an orthopedist. The latter reluctantly cannot jump to the knife right away (case management and all) so he orders some physical therapy. A couple of months later, patient comes back still in pain so the orthopod refers him to a pain specialist. The latter schedules a series of spine injections. Patient returns a few months later to the orthopod. Of course he is deemed still not improved but his MRI is inconclusive so he is sent back to the pain doc for a discogram, the results of which usually give the orthopod the license to cut he was waiting for, complements of the grateful pain doc. About 3 months later, the patient with more hardware in his back than the Eiffel Tower, is in even more pain so he gets sent back to the pain doc who rachets the pain meds to a point. Patient is still miserable so a trial of spinal neurostimulator is now warranted, which basically aims at distracting the pain versus eliminating it. Patient is deemed to have passed the trial successfully, whether it is true or not, so now he is referred back to the spine surgeon for permanent implantation of said stimulator (another open procedure under general anesthesia). As this Ping Pong game continues, the doctors and the device manufacturers prosper (or at least the latter) and more GDP is gobbled up by the US healthcare system. Of course the very expensive stimulator usually stops working within a year and occasionally the Ping Pong game includes another match: implantation of a morphine pump. More often the patient now has put in enough time in pain, misery and out-of-work time to qualify for disability income from Social Security...et voilà, le tour est joué! as the French would say.

Besides the above duet or trio ensembles, larger ones are common ground in multidisciplinary practices, i.e. quintet or sextet. A patient walks into his generalist complaining of joint pain. After the usual history and physical, he gets referred to the colleague next door who happens to be a rheumatologist. Same scenario, different blood work and now a referral to the orthopedic surgeon partner. Noblesse oblige, the latter has to obtain various imaging tests so the patient is off to the radiologist of the group. God forbid the surgeon smells anything operable, the patient then has to see a cardiologist to clear him for surgery. More tests are done in the practice's laboratories. Often, for "convenience" of course, there is a pharmacy on site and the medications are provided there as they are prescribed by the members of the medical quintet. In this case referrals are indirectly lucrative to the various members of that quintet whom are all partners of the medical corporation. There is clearly NO incentive to cure the patient swiftly and definitively. It would be bad for business and not tolerated by the administrators. The longer the patient is in this loop the better...unless of course his insurance runs out, then his healh is deemed to have improved drastically over night and he is discharged.

Although lawyers for example can refer to each other to their hearts content, doctors are legally barred from doing so by the STARK Laws so. Nonethess the above scenarios seem to be convenient loopholes to get around these laws. Another example of the proverbial toothpaste tube: you press on one end and the paste exits the other end.

If a doctor, mindful of the DO NO HARM clause in the Hippocratic Oath, and maybe also responsible enough to be concerned with the rising healthcare costs, has the temerity to adopt "The buck stops here" approach  instead of the "passing the buck" approach by refusing to play the referral game, all hell breaks loose: he will get no referrals from his colleagues because he does not "play ball" and if he manages to survive from word-of-mouth patient referrals because they see in him the real deal, the colleagues' ire and jealousy will increase even more and they will not hesitate to complain about him to the Medical Boards. The latter are usually manned by old timers who grew up in a different era when the medical referral game was the only game in town and the medical specialties were so stringently defined that you practically needed a visa to venture from one to another.

The advent of minimally invasive techniques and technologies did blur those specialty boundaries, especially between conventionally surgical and non-surgical specialties, but the carriers stubbornly call them experimental so as not to pay for them and the Medical Boards maintain a very skewed interpretation of the certificates they award which read unambiguously "License to Practice Medicine and Surgery".

To end on a historical note, Dr Watanabe who invented knee arthroscopy in the mid 1970s was a Japanese rheumatologist. Need I say more!

Shrek-like Stuffing of Mr Healthcare Turkey

Imagine if Prevention catches on in America how many people will be out of business. The healthcare juggernaut will crumble. A number of job categories will have their ranks decimated like nurse case managers, insurance adjusters, healthcare administrators. Hospitals will close and nurses wages will go south. Doctors will have time to actually see their fewer patients and not worry about lawyers as much.

We have long reached the point in this country where the healthcare system does not exist for the patients but the other way around. The minute you cross a hospital threshold you become a number with a bracelet on your wrist. Have you ever paused at the number of papers they have you sign, and how many people you have to deal with who are NOT YOUR DOCTOR. Your main purpose becomes FEEDING THE HEALTHCARE OGRE.

My notebook is replete of stories of healthcare OVERUSE. How many of you do know somebody who entered a hospital for a right knee pain only to be discharged a couple of weeks later with his liver biopsied, his prostate turped, his left shoulder scoped, his left knee replaced,,,,and STILL complaining of right knee pain! Once you enter the healthcare machine God only knows what you will end up with...or without. EVERY HORSE IS CONSIDERED A ZEBRA UNTIL PROVEN OTHERWISE, meaning that any artifact on an x-ray, any borderline number on a bloodwork, or any EKG misfire will only lead to more tests and more unnecessary procedures.

That is what happened to me after my scooter accident of 1988. I was riding on Flatbush avenue in Brooklyn and a truck cut me off at a green light so I ended up pinned under it saved by my scooter and helmet which got wedged there. The rear wheels pinned my leather jacket and I lost consciousness when I broke most of my right fingers trying to get my right arm away. In a nutshell the brunt of it was in my right hand. Luckily or not, I ended up in a local hospital which just received its trauma designation and was itching to show it. First and foremost, doctor or not, you are the patient so you should just shut up and let them do to you what they wish. It all started with a chest x-ray taken laying down because they had not yet cleared my cervical spine due to a busy CT scanner. Of course anybody knows that you take those x-rays sitting up or standing. Sure enough there was  positional distortion in the aortic segment but the attending decreed that it maybe was an aortic dissection and the hell started: an arteriogram was warranted meaning must first do a mini-lap to rule out blood in abdomen and before that of course a Foley catheter you know where. All that was negative. I was so worried about my right hand (my surgical future and all) but nobody cared and I had to literally freeze in the hallway waiting for my cervical spine brain and chest CT scan. Finally it was done and also negative. So now I was ready for my arteriogram, the biggest torture of all, causing me to burn inside and puke my guts out, also negative. After all these negative tests were done, to the tune of about $20,000, some hand surgeon finally addressed my mutilated right hand 7 hours later If they had listened to me in that freshly minted trauma room they could have saved me quite an ordeal and saved my insurance a great deal of money.

The ER is a bottomless pit geared towards heavy-handed defensive doctoring with a dose of high pitched theatricals and disdain for cost.If you can pay the price of waiting for hours, the minute you are admitted it is the TAJ MAHAL of tests, probes and pokes. All bets are off regarding HMO, PPO, precertification, predetermination or any other feeble attempt at cost containment . You are theirs to handle as they please. This plays nicely into the American fast fix and immediate gratification mentality that we discussed in previous blogs.

ERs are by law forced to take everybody, with or without coverage, with or without citizenship. What ends up happening is a Robin Hood approach where the insured patients pay for everybody else, thus the prices they are charged are exorbitant. Considering the public fondness for the ER Taj Mahal, no wonder insurance costs are rising.

PharmaEconomics: Are we duped or accomplices?

Most americans probably own some big Pharma stock in their portfolio and/or retirement account. If sales increase, the stock value increases and the investors do well. Thus, since many of us profit from big Pharma profits, we are their de facto accomplices: when they charge exorbitant amounts of money for their medications we should not complain...or should we?

The truth hit me like a ton of bricks in 1991 when I was invited as a speaker to an International Conference in Shanghai then Visiting Professor in Beijing, My back was hurting from all the driving and flying and I asked if I could have some Feldene (it was the fashionable  nsaid at the time and Pfizer was really taunting it with ballerina posters all over). The driver went into a pharmacy and got me an entire box. I thought to myself that I really did not need all that since it must cost a lot of money. The fact was that I bought 20 pills for the equivalent of $10! In the US those 20 pills would have cost close to $250.  So how do we explain this?

The simple explanation is that the American taxpayer single-handedly pays the high price for medications, thus supporting all the research and development and the FDA process, and bolstering the stock value. Be that as it may, America represents only 5% of humanity, so after that new pill is discovered and is out on the market, it also becomes just as available all over the globe at drastically lower prices. So 95% of humanity benefits from this new medication at very low cost while 5% foot the tab. This is when the accomplice becomes duped! This price disparity is staggering and one can only wonder if the costs were shared by 50% of the world population for example instead of 5%, how much cheaper it will be for us.

Big Pharma does make sure we pay the high price by sponsoring laws and regulations forbidding us from filling a prescription or obtaining medications from abroad. However bus loads of US citizens cross the borders to Mexico or Canada to get their meds. The movie "Love and other Drugs" shows a group of seniors traveling regularly to Canada for this very purpose. The advent of the internet is allowing some to circumvent these laws. I saw Viagra advertised at less than $2 a pill recently (US price $15). Can you believe that? I do not know if it is 100% legal but the pills look legit and seem to be coming from Germany. I am sure Pfizer would not condone this but think for a second: an american company invents the pill in America and sells it here at a very high price but quite cheap elsewhere, so that pill reenters the American market through the back door at a price that is a fraction of what it started with! That is PHARMAECONOMICS for you!

Another example is Victoza, an excellent medication for type II diabetes, which literally saved my life. The 180 mg pen is worth $180 in the US, often despite insurance. My sister bought me the exact same pens, in the exact same packaging, from Lebanon for $80 each. For me it is a saving of about $300 a month. Food for thought!

Big Pharma justifies the big costs by blaming the huge R&D expenses and the tedious and lengthy FDA process. I do not know about you but I am not very impressed by the latter. How many FDA-approved drugs have you seen being blamed for unknown complications and pulled off the market in recent years? Bextra, Vioxx, Avandia, Actos, Ephedra, to name a few. The 1-800-BADDRUG lawyers are beaming and one can wonder if they are in cahoots with the FDA. Despite all the money it receives from big Pharma and others, the FDA has been lackadaisical lately: salmonella epidemics in food, fungus-tainted steroids that  caused meningitis in 440 people in 12 states and killed 32, etc. Maybe they should streamline their processes and save resources and man power to be able do more inspecting and troubleshooting. .

Another thing that protects big Pharma is their patents. These last 17 years but they are really only valid in the US and maybe western Europe. For sure India and China (3 billion people) couldn't give a hoot. When the patent is about to run out, they modify the medication a little call it Extended-Release and off they go for another 17 years, instead of supporting and producing the impending generic form which is much cheaper.

The issue of patents is so dear to big Pharma that they are willing to sell their soul to the devil for it. Some of you may remember the Women's Health Initiative (1991) which addressed 161,808 postmenopausal women who were taking Prremarin and Provera (synthetic Estrogen) and concluded that estrogen supplementation was not recommended in this population because it increased the rate of breast cancer and cardiovascular disease among others. So for years thereafter, endocrinologists and gynecologists were scared to prescribe these drugs and millions of menopausal women preferred to suffer for years with hot flashes and all kinds of misery because they were afraid too. The raw truth is that BIOIDENTICAL Estrogen (as in Yam and Soy) is perfectly harmless and has only positive effects on the body. The only problem is big Pharma CANNOT PATENT a bioidentical hormone. They had to modify a bit the natural molecule to synthetize Provera, just enough to be able to patent it, but sadly also just enough to cause all sorts of complications. Besides, the treatment with bioidentical hormones costs less than $50 per month whereas Provera was close to $10 a pill.

Something else you should know about big Pharma, they love to develop and produce new narcotics. For every new cancer drug that comes out, there is at least two or three new narcotics as if we needed yet another one of those. The latter are easier to produce (most are byproducts of morphine, codeine or oxycodone) and SO lucrative. Not only people cannot get enough of them (once hooked, you want more and more) but they are also sold at a high premium on the street, unlike cancer pills or any other life-saving medication. It is PharmaEconomics 101: Do the Math!

Accomplices or duped? I let you decide

No Pain No Gain$$

The “No Pain No Gain” adage is commonly used by coaches and teachers in sports and in arts. It implies a certain amount of physical suffering and perseverance, with a touch of mental catharsis, to improve ones performance. This is usually the stuff that Olympians and virtuosi are made of. Of course with that level of achievement usually come more $$ and rightfully so.

My use of this adage in this blog is merely satirical aiming to raise awareness. Assessing pain levels is a true obsession nowadays in medical facilities with charts on all the walls, depicting frowny faces of various degrees, and numbers from 1 to 10 out of 10 (VAS) or otherwise.

Often I felt as a clinician that assessments and complaints of pain were exaggerated in as much as they were not supported by any other observations, i.e. physical and physiological findings. It is hard to have a 10/10 pain level if your pulse and blood pressure are quite normal. In part this exaggeration occurs because it often leads to some sort of compensation and reward: “Squeaky wheel gets the grease!” When I was a volunteer with Orthopedic Overseas in Ethiopia in 1985, every time I mentioned back pain in this country of 45 million, they looked at me as if I was from Mars. I saw little old ladies carrying heavy loads of wood on their backs for long distances or younger people sitting on the floor crouched for hours in the marketplace. My own back could not stand the rides on buses with busted shocks. I had a grimace the whole way. The Ethiopians are not made differently…they just complain differently: few if any lawyers around and no pill-popping mania. They were too preoccupied by mere survival and fighting real illnesses to pay any attention to something as westerly mundane as back pain. Be that as it may, the latter cost more than $50 billion a year in the US alone.

PI lawyers do instruct their clients to duly complain of pain every time they see the doctor, to pad their case. Patients often tend to inflate their proclaimed pain level to help convince the doctor they need more drugs. It is not uncommon to see a patient waltzing into your office with no assistive devices, having driven themselves there, yet complaining of a totally unrealistic 10/10 pain level (bedridden pain level). Pain is indeed quite subjective this way so clinicians simply have to dig further to establish the true level, if they would bother. Many do not. For an average $50 a visit (and discounting), they will gladly give you an Rx and send you on your merry way, with a smile, and you will surely come back. That is all the time they can afford to spend. Unfortunately many an addictive personality has been encouraged this way.

Every time I argued with a patient about their true pain level and the unsustainable amount of narcotics they were taking and/or demanding, I created a true enemy who went and slandered me on the internet or worse. It is hard to try to do the responsible thing in a land that stopped condoning it.

I had a patient who would give me a 10/10 pain level at every visit so I decided her pain medication was not working and needed to be changed. She became extremely distraught and admitted she inflated her pain level because she was told that is how she would convince me to prescribe more pain medication. Hmmm!

A doctor acquaintance of mine called me from CT about 3 years ago all upset. One of his patients on disability was selling his Oxycontin prescriptions for about $11,000 a month and he was caught. So much for unemployment benefits! This doctor was a bit of a scrooge and got played, but some doctors actually fuel and participate directly or indirectly in the prescription drug trade. Watch for Pain Clinics open daily till 1:30 am where only cash is accepted!

In America, more than any country in the world, including Western Europe has developed a whole gamut of cottage industries around PAIN. From getting monetary compensation (the grossly abused pain and suffering) to selling ones pain medications on the street.

A huge amount of healthcare dollars is used simply to try to prove or disprove pain, because the patient is too often not to be trusted and secondary gains run the show instead of the actual symptoms. This state of affairs has crippled the all too liberal New York State Workers’ Compensation system. I have seen patient on full WC benefits for more than 20 years after a simple lumbar strain with not even a single MRI finding. This kind of dependency becomes a mode of life that is extremely hard to reverse. Statistics have shown that after 1 year of being out-of-work the chances of return fall to 25%.  It just so happens that after not working for 12 months, the claimant can now apply for Social Security Disability to boot and have Medicare coverage soon after.

From dependency stems entitlement and the vicious cycle continue.

Mr. & Mrs. Pillpopper, the all-(too)American Family

Coming from Europe, America is the country of FAST everything: fast food, fast fix, fast buck (casinos, Wall Street), fast cars, fast communications (cell phone, twitter, facebook etc.) fast shows...even Fast and Furious! Is this stemming from the American business adage: "Time is Money" or is more a byproduct of immediate gratification need with its corollary of laziness and gimme attitude? Both are not very sanitary for society in general.

They eventually lead to a product like Exercise in a Bottle which hit the market a few years ago. You cannot get a better short-cut than this. It is not just disingenuous but also anti-physiological yet it did sell and probably still is.

Pill-popping is indeed quite epidemic in this country, as compared to the rest of the world. Even those who are not taking any medications manage to pop a couple of dozen vitamin pills a day. It is the fast fix mentality. There is a pill for just about everything, even lengthening one's penis (at least the Pharaos used weights for traction!). Often pills are taken to obliterate the side-effect of another pill, like anti-acids with anti-inflammatory medications or those quinquagenerians on testosterone need often to also take Arimidex (breast cancer pill that inhibits estrogen) to inhibit conversion of some of this testosterone into estrogen.

It is a thriving market. Pill-popping would probably be inocuous if it was not for the addictive quality of a number of these pills and the criminality related to them, i.e. narcotics, sioporifics, hallucinogens, anxiolytics, antidepressants, etc.

Whether it is from a doctor, a dentist, or from a "friend of a friend", Mr. & Mrs. Pillpopper ususally have an assortment of these addictive drugs stowed in their medicine cabinet at home. Pillpopper Junior gets a hold of them and brag to his friends. They do the same and soon a PHARM-PARTY (nothing to do with agriculture) gets organized where all the juniors dump in a large bowl their pill-catch of the day and they mix it up and sample nonchalantly. Best thing about it is that it cost nothing and it was prescribed by a doctor...how can it be bad for you? These pills are hard to swallow so they are often downed with the available alcohol (never mind the red label. The detailed label printed by the pharmacist had long divorced its contents).

This is somewhat satyrical and could be borderline comical if it was not so tragic. I heard several times now about the dumbing of society starting by the younger generation. I am sure pill-popping has a lot to do with it a long with increased obesity, lack of exercise, texting (with its uncanny abreviations), e-communications and iclouds. But look at the bright side: we maybe inventing a pill soon enough to reverse all this. Wouldn't that be cool? An anti-dumbing pill would even rival "Exercise in a bottle".

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No Wonder the Brits call them "Solicitors"

NO SOLICTING ALLOWED is a sign you often see at the door of establishments and other places. Doctors surely are not allowed to solicit so aren't salesmen, prostitutes and other professionals but lawyers are exempt. As a matter of fact they seem to be encouraged and fed information by the powers at be judging by the unsolicited letters people receive from lawyers offering their services. I certainly received my share over the years. Once I even found out first about an unpaid speeding ticket when I received a letter from a lawyer I did not know offering to represent me! LAWYERS DO HAVE THE POWER AND THE ACCESS. Look at who is governing us. Not a theocracy, a bureaucracy (that too!), an autocracy or even a democracy (fallacy!) but a Lawyocracy (term coined under the Clintons and certainly very much alive under the Obamas).

What fuels this intensive soliciting is the contingency remuneration of most lawyers, especially in Personal Injury or liability law. Think about it: the more misery you are in, warranting hopefully a larger settlement, the more money your lawyer makes as a percentage! Hence the terms: bottom-feeders, ambulance-chasers, etc. In Western Europe, lawyers are paid hourly like any other professionals. If that was the case in the USA, think how many frivolous lawsuits will be avoided from the get-go and think how much money the healthcare system will save especially. Why should lawyers be the only professionals paid based on outcomes? Why not accountants for instance or doctors? The latter spend the longest and costliest amount of time studying and the rest of their life being credentialed and recredentialed, scrutinized and regulated, only to find their income going steadily down from year to year. In part because of the lawyers, they have to pay higher and higher malpractice insurance premiums to boot. Forget about any bonus for a good outcome but good forbid one single negative outcome befalls a doctor.

Perhaps the most striking abuse of this contingency remuneration is the CLASS ACTION SUIT. All that the firm needs is about five complainants with similar gripes and they have the all too lucrative class action suit, meaning they can be looking for settlement multipliers. Look at how much money was made by the lawyers in the tobacco settlement, the asbestos settlement, and even the Holocaust survivors’ settlement! The math is frightfully simple: Let us say a law firm is awarded a million dollar settlement for a class suit of 100 plaintiffs. The firm will take about $350,000+ off the top and the 100 plaintiffs will divide amongst themselves the remaining $650,000 meaning $65,000 each which is only about 1/6 of what the lawyers made! That is all the more unconscionable as those plaintiffs could be dying form cancer or be Holocaust survivors or worse. Where is the fairness in that?

Nothing classy about these Class Actions which recently seem to be targeting more and more the Healthcare industry, i.e. pharmaceuticals (1-800-bad-drug) and medical devices manufacturers (hips, knees, etc.), thus raising the costs for all of us healthcare consumers and insurers. How is that addressed in OBAMACARE? I doubt it is since lawyers undoubtedly take care of their own.

To illustrate the above, I was personally the victim of a Vespa accident 24 years ago. Of course I had to hire a lawyer who was promptly referred to my ICU bed by my orthopedist, with documents in hand to sign (with my left). I did not play my role very well like my lawyers instructed and discharged myself AMA from the ICU to go back to work. I also did not follow the script at the deposition (I was simply glad to be alive despite having been pinned under a truck). When I explained that very fact to the junior lawyer and that I was not a freeloader but would rather work hard and earn my living the old-fashioned way for myself and my family, he said outraged something that I will always remember: “what about my kids?!”

Last summer, while on vacation at DR I met a lawyer who was awarded a 9.5 million dollar malpractice settlement (his share about 1.6 millions). It was a slam-dunk case and he lucked out because of religious connections. All he had to do is write a long letter to the CEO of the hospital. That put his rate at about $10,000 a minute. Not too shabby!

I also have another legal friend who has for me a standing offer: "Refer to me a paraplegic or better a quadriplegic and you will not have to work another day in your life."  Believe me I have been looking!
!"

Working the (PI) case:

If you ever have a car hit you WHO YOU GONNA CALL? No... Not Ghosbusters! but your friendly neighborhood law buster who just got a nice little settlement for your friend's girlfriend. This is indeed the only civilized country in the world where after a car accident you often call your lawyer before the police or the ambulance (of course your lawyer will insist that you call an ambulance and got to the ER. It is all for the GOOD OF THE CASE...Never mind the cost of all this and never mind that you are tying up valuable resources that you really do not need for that mild whiplash injury).

In the ER, first comes imaging. You absolutely need to document. If you do not have a herniated disc you do not have a case. The radiologist knows that so s/he after obliges. Their motto "Every horse is a zebra". Thus every other bulge becomes a herniation of some flavor. Radiologists never get penalized or sued for over reading so why not oblige. It is good for business. Of course the more herniated the disc is read to be, the more of a license to cut the surgeon will get, carrier beware. The sad truth is that MRI is becoming more and more a test for lawyers and judges more so than a diagnostic tool for providers. Jurists are seen in court brandishing these films and daring each other as they submit the jury to a grueling deciphering of these very fancy and elusive pictures. Doctors safe happy to tutor...for a fee! It is all fine and dandy but the price of this expensive "black-and-white two-dimensional as you lay very still and horizontal" (so unlike real life!) test is close to a grand!

At the center of all the fuss resides the chiropractor MANIPULATOR PAR EXCELLENCE. First every patient has to receive a set of x-rays when they walk-in and every single patient is then told that they have something out-of-wack in their spine. Of course the patient is never told that even a slight movement of the neck up down or sideways, while x-ray is taken, will cause a pseudo-abnormal x-ray thus providing the chiropractor a license to manipulate....for ever and ever...or should I say until the insurance benefits run out! Most treatments in healthcare are time-limited, e.g. antibiotics for 10 days, nsaids for 2 weeks, cast for 6 weeks, etc. Only chiropractic is indefinite, more so if you have a personal injury case. Isn't this strange?

The big spoiler is the Independent Medical Examination (IME) whereby a doctor completely foreign to the patient or his/her case, often from another state, is hired by the carrier to "objectively" examine the patient and determine if any more treatment is needed and what. These doctors are usually IN DEEP with the carrier not independent in the least. They proclaim from the get-go that they do not have any doctor-patient relationship with you and will be only conducting some sort of forensic examination in relation to the accident and the alleged injuries. Many patient describe that examination as very cursory and often borderline hostile. These IMEs are very lucrative and often times paid in full upfront (a true dream for doctors who often have to fight tooth and nails to get paid 50% of what they billed). Neurosurgeons and orthopedic surgeons can literally make $1 million a year just doing IMEs. Some of these IMEs can lead to depositions or court testimony...this means more upfront no hassle moola! These would be considered Defense-doctors and their sole focus is to cut-off the care and get the carrier of the hook. The more they do that and the more business they get. So much for independence. Essentially these doctors have read the Hippocratic Oath upside down for they aim to deny care instead of providing it and the "do no harm" is out the window.

Indeed in compensable and personal injury cases, often more money is spent by carriers on these IMEs that deny care than on actual treatment! This IME practice would be a sad reason to go to Medical School and I have yet to discover anything similar in Western Europe for instance.

Get Medical Care and hit the Jackpot ... The American way

The savvy american patient has many ways to cash in on his medical care. We discussed the "build-my-case" approach in the personal injury domain (auto accidents, workers' comp, slip and fall, etc) where the PI lawyer is usually the de facto HMO case manager and the chiropractor the gatekeeper of the case, bringing in the specialists in rotation to build-up the medical bill and enhance settlement. More surgeries = more monies usually. Lawyers greatly encourage those to increase their bottom line. After all they are not the ones putting their bodies and lives at risk.

Patients are often proclaimed permanently disabled after these PI related surgeries and they are now cashing in on disability policies and/or Social Security Disability benefits (SSDI) at a relatively young age (usually in their forties). From the files I saw in Bethesda in the late 1980s, when I was awarded a grant by the Social Secutity Admnistration, about 40% of the people on SSDI were diagnosed with failed back syndromes and most of those were subsequent to MVA, WC or slip and fall injuries. The median age was mid-40s. The taxpayer will be supporting these "disabled" people for an average of 50 years! How could any economy afford that?

Following this all too common tableau, the now surgerized and disabled patient is very often in a lot of pain due to post-op morbidity, scar tissue, deconditioning and long periods of inactivity and convalescence, or at least claims to be. There is increased need or at least demand for narcotic medications. The more scars and hardware they show the more they can get providers to prescribe huge amounts of narcotics. These officially disabled patients, who have little official income left besides their SSDI, find it usually very tempting and lucrative to sell all or most of their narcotic medications on the street ($1 per  1mg for Oxycontin!), therefore cashing in in yet another way on their injury and medical care.

Such a multi-faceted and prosperous business bourgeons around a compensable injury in America unlike any other similarly advanced and civilized country. The incentives are too strong and too many parties profit form it. It is indeed one rare occurrence of lawyer-doctor complicity so Obamacare and Washington beware.

The Federal Government wants to save money by cracking down on fraud and abuse. The scenarios explained above are perfect examples of such except that there is no smoking gun. Surely one can say that a lot of these surgeries are unnecessary and that can be labeled as abuse, but you will always be able to find a doctor who says otherwise...for a fee! In a number of trauma-related related specialties, there are only two kinds of doctors, as in lawyers, defense doctors and plaintiff doctors, the difference being the payor.

Obamacare and Personal Injury

How is Obamacare, which is now inevitable, going to affect the No Fault insurance coverage, as in motor vehicle or workers' compensation accidents, or even slip and fall? Many medical specialties, e.g. orthopedics, neurosurgery, pain management, radiology, anesthesia, neurology, rehabilitation are probably wondering about this right now, as I am sure are the numerous lawyers specializing in personal injury. For one, these "No Fault" systems are very much State-specific in their rules and regulations, while Obamacare is nationwide. If Obamacare seriously plans to reduce healthcare costs how could it not also tackle the healthcare provided under the cover of some legal umbrella, be it motor vehicle, workers' comp, slip and fall, or any third party liability.

I have practiced medicine in the Middle East, Africa and Western Europe, The only country in the world where patients go to the doctor quite often primarily to "make money" is right here in America. Sustained a fender bender? call Fender & Bender Law immediately and they will pull out of the desk drawer a stack of business cards of their group of loyal providers, usually headed by the local chiropractor who is the "build-the-case" expert. If you have other passengers in the vehicle, the more the merrier! Personal injury is a HUGE business especially in some states. One's auto insurance usually pays better than Medicare or practically any commercial insurance these days. Unlike the latter, Comp or auto carriers are readily subject to legal and arbitration procedures and providers will ultimately get paid even if it is 1-2 years later.  Actually this arbitration process is very familiar to those PI providers and the lawyers who refer the patients to them and charge extra to do those arbitrations.

Reducing healthcare costs is furthest on the minds of these PI patients and lawyers, As a matter of fact patients are instructed routinely by their lawyers to diligently visit this or that specialist "on the team" to run up the tab, and even to undergo this or that surgery, regardless of risks, to build their case and increase their settlement value. Afficionados are aware that settlements are largely calculated based on the amount of medical bills. The more surgeries the better! Nevermind if disability ensues, Medicare and Social Security are right there to bail you out! By the way the latter behavior trend is what caused the doubling of the number of people on SSDI in the last ten years, with all the added costs to the nation.

In summary the healthcare system is like a toothpaste tube. You squeeze one end it comes out of the other. As it is, many patients try as best they can to receive their care under a No Fault system because not only they can get more eager providers to care for them this way, but they can also make money to boot. What a deal! I doubt Obamacare will do anything about this state of affairs because the lawyers in the country will not allow it, and they are the ones governing us.