Flying the Friendly Skies to your Doctor's Visit

Medical Tourism has gained a lot of momentum in the last decade: It started by polish, lituanian or other immigrants returning to their mother land for dental work which we know can be very costly in the US. There is also the South American ladies (Columbians, Brasilians, Ecuadorians, Mexicans, etc.) going back home to undergo cosmetic surgery for cheaper prices. The latter bunch are finding the prices more and more competitive here and the added bonus of better post-op care and especially the ability to sue the doctors to their hearts content. Of course dental and cosmetic can be considered as retail business non-insurance based, where patients shop around for the best price here of abroad.

What has been happening more and more though is patients going abroad for bona fide surgical procedures such as back fusion. First there is the fact that a large number of doctors working in South America (Costa Rica, Panama) and in India are trained in the US then return to work in their countries. Second there is the other fact that private accrediting agencies such as JCAHO and AAAHC have been also active internationally. Indeed many private hospitals in these countries can now claim that status. Third there is the trivial fact that a two-level fusion would cost no more than $15,000 in Costa Rica, all inclusive with the vacation to boot, while it can cost upwards of $200,000 in the US! Looking at all these facts, maybe Medical Tourism is THE remedy for our healthcare costs, what do you think.

The US-trained Costa Rican surgeon is not using plastic screws and plates for this fusion! He is using bona fide titanium hardware, same as the devices used here, so what gives? The truth is that  the same screw that costs the surgicenter or hospital $3000 per unit in the US is bought for close to $300 there. Why? good question. Among 95% of humanity nobody pays as much as we do for medical implants, just like Pharmaceutical drugs (see PharmaEconomics). This $3k screw can end up costing 2-3 times more. Here's how:

There are companies out there called Third Party Billers TPB which build some solid relationships with carriers, commercial but especially auto or WC, whereby they would buy the hardware for you to implant and bill those carriers for it so you (usually private surgical center) do not have to spend that large amount upfront then wait to get paid. That is fine and dandy except I discovered fortuitously once that the third party biller I was using TRIPLED the cost of the device in their bill to the carrier and worse THE CARRIER PAID FOR IT without flinching while beating down our bill.  The net result was that the TPB got paid more than  twice more than our facility got paid, while we did all the work and paid all the related expenses, and they did not even have to meet the patient or do anything beside brokering the deal. Doesn't that baffle you? Only in America! This kind of out-of-balance remuneration is of the same order as the lawyers take in class action suits (see Solicitors blog);

How can we supposedly thrive for social justice when brokers, lawyers and other go-betweens keep getting paid exponentially more than the victims, patients and other interested parties, while doing a lot less work and having a lot less costs and liabilities. There is also the issue of pursuing the highest of Higher Education to end up getting paid half as much as a simple broker. What should you tell your children about that or about working hard?

Maybe the secret to right this wrong is Medical Tourism. Those kinds of disparities do not usually exist abroad where the cost is ALWAYS less no matter how you slice it.

Brokers here or medical tourism abroad "Good Fortune Favors the Bold" (Alexander the Great)

Best when Served Fresh, Cool and Au Jus

This is not a gastronomical or culinary post I assure you. I am not a good cook by a long shot. This is about stem cells believe it or not. Those cells are known to be the mother cells of all organs in the body. They can be found literally everywhere in the body: skin, bone marrow, blood and especially fat. There has been quite a controversy about the use of stem cells in research and medicine because they were all believed to be coming form embryos, more specifically discarded embryos, i.e via abortions or in vitro fertilization. In the last decade, parturient mothers have been storing the umbilical cord blood of their newborns and that yields a number of stem cells that are multipotent and especially can be passed on to a sibling suffering from leukemia for instance. Actually some parents have decided to have a baby especially to aid another child.

 Recently we are beginning to distinguish readily between embryonic stem cells, and cord blood and adult stem cells. The Vatican published a paper last year supporting the later research at the expense of the former of course. Grant funding have been guided accordingly trying to steer away from embryonic although constraints have been lifted lately by our government. The discussion is now more of an FDA discussion. How much can these cells be multiplied and induced to differentiate prior to reinjecting them before the FDA can call them a drug and start applying the same rigid protocols it does for the pharmaceuticals. We all know that these processes are far from error-proof (refer to blog on PharmaEconomics). Although blood is commonly auto transfused, and skin is often taken from one part of the body to graft on another, same as arteries, veins and nerves and no FDA approval is needed for all that.

When it comes to your own stem cells, even if they are not manipulated or very little, the FDA wants to treat them as a  drug if you plan to reinject them. They may give a narrow pass to your bone marrow cells being reinjected into your bones, joints and tendons because it has to do with blood, but they will not see the same way adult adipose stem cells AASCs. These are mesenchymal in nature meaning they are from the same lineage as tendons, ligaments, joints, nerves, muscles, etc. Most importantly there are A LOT of them about 500x more than bone marrow far example and they are easy to retrieve via mini-liposuction. A small amount of fat is aspirated, ASCSs are extracted in great numbers and can be used within 30 minutes IV or IA on the patient him/herself "Fresh, Cool and Au Jus"; or more scientifically "autologous". Doctors OUTSIDE the US are using this cheap and simple methodology to treat a large number of conditions: shoulders, knees, macular degeneration, cerebral palsy, multiple sclerosis, autism, paraplegia, you name it.

 When I attended last years meeting of the International Society for Cell Therapy (ISCT) in Seattle I witnessed the reason why I think the FDA is taking this approach. Millions of dollars in grants are being distributed to many prestigious university laboratories, only matched by large investments from GE, Unilever and others, are going into this arena, primarily for embryonic, cord and hematopoietic (from blood) stem cells. An inordinate number of workshops was offered on the business and commercialization aspects of this field. Then it dawned on me that the FDA does not want to support any autologous approach (where doctors do it on the spot in their office) nor it should or knows how to do that. They want to put the weight of their bureaucracy, funding and regulations on the side of the allogeneic research, meaning that patient A would be getting processed shrink-wrapped cells from patients XYZ. This indeed is the pharmaceutical model they are most familiar with and they can easily implement, as compared to monitor individual doctors' offices throughout the country. Besides this is where the money multipliers are, just like new drugs on the market. Of course big Pharma wholly support that because they can commercialize it and make money from it. You can already buy about 1 cc of dried up cells in a bottle for about $5,000, like you would a pharmaceutical drug.

So what happened with HEAL THYSELF (see previous blog)?. Using your own stem cells for repairs throughout your body certainly fits this golden principle. AMERICAN CRYOSTEM very energetic and ambitious company, considered by Forbes second in the country for stem cell storage and banking, found a very innovative way to respect the Heal Thyself principal without infringing on FDA policies: They are featuring personalized and customized cosmetics populated by your own AASCs extracted from your own body, that are delivered to your doorstep every month. Cosmetics are indeed a lot less FDA regulated and American Cryostem's ingenious idea skirts all that and delivers these cells back into your body month after month, for a fee of course. Pilot studies in California have already showed skin improvements, i.e. wrinkles and elasticity. The real question remains can this delivery mode bring enough AASCs into the general circulation to effect more systemic conditions. It remains to be seen but FDA STAY AWAY... for now!

Heal Thyself and your Years be Golden

The human body is actually quite equipped to do just that. there is tremendous redundancy in tissues (skin, vessels), muscles (424) and organs (2 kidneys, lungs, eyes). Every human tissue has its own repair mechanism with progenitor cells, stem cells and others. after blood loss or blood donation, your bone marrow will eventually replenish your blood volume.

Facts tell but stories sell: There are amazing such stories out there of survival in the ocean, in the desert, in the snow, with no food or water. The human body can endure a lot and given enough time will heal what is broken or diseased.

I have often presented this to my patients in the following way: The rate of recovery R (from a fracture, injury or even disease) is the ratio of healing H over reinjury Ri : R = H/Ri. The higher the rate of reinjury (reinfection or disease spread) and the slower the recovery. Similarly the higher the healing potential and the faster the recovery. Of course H varies with age, habitus, comorbidities and genetics (immune system, DNA). H can be maximized by adopting rigorous WELLNESS regimens (refer to previous blog), improving one's bad habits (smoking, alcohol, drugs), killing all free radicals with antioxidants and proper bio-available nutraceuticals and nutrients. One thing for sure, H does not apply to implants, hardware and prosthetics. The earlier you get one of those implanted in your body and the sooner you would be needing mechanical repairs versus biological. Food for thought.

Given enough time, the body will do marvels repairing itself but remember we are in a Fast Fix Immediate Gratification Society (refer to Pillpopper blog of 11/14). We want to fix it now, cut it out, make it brand new, even if it ain't broken or barely. This remind me of people who would make the damage to their car or home worse so as to get better insurance coverage and get beyond the deductible.

Several years ago, an article in the New England Journal of Medicine followed a cohort of 2,000 back patients for 2 years. They all had similar diagnoses but they followed two very different paths: one group had surgery early on; the other just conservative treatment or none. Both groups faired the same after 2 years of onset. Obviously the second group was an advocate of the Heal Thyself doctrine, while the first subscribed to the Heal Me NOW doctrine. The latter probably cost a lot more money and causes a lot more complications and morbidity for basically the sam result.

Today people are living longer and they want to do it without spare parts in their body. Heal thyself is considered as the safe way to go and it is one of the tenets of the ANTIAGING tsunami.

H (healing) can also just as well represent hormones. Indeed our healing powers are highest in our younger days when the hormones are plentiful and raging. They play a big role in healing and prevention of disease. Rarely you hear of a 20 year old who has cancer or a heart attack. One of the core principles of Preventive and anti-Aging Medicine is to restore the 40-50 year old hormones to their 20 year old levels. It is based on OPTIMIZING blood hormone levels (thyroid, DHEA, testosterone, estrogen, progesterone)  not just NORMALIZING, meaning shooting for the upper level of normal (for the 20-25 age group) for each hormone. Another core principle, is using BIOIDENTICAL HORMONE with molecules similar to ours and derived from natural substances such as soy and yam. The best way to obtain those is in compounding pharmacies. The pharmaceutical hormones on the market are synthetic thus often harmful...and a lot more expensive (refer to blog on PharmaEconomics).

May West said it best: "If I told you I like my body would you hold it against you?"...or something like that

Does Wellness Trump Health?

This is not a religious blog but I cannot help but making the following analogy utilizing religious figures: Jesus Christ is always depicted as fit and svelte but with a serious rarely smiling almost gaunt face. He could be the Health poster child. Buddha on the other hand is cheeky smily bon vivant with a big belly. He could represent Wellness. The latter wins demographically with more followers, so does this mean that WELLNESS TRUMPS HEALTH?

With Christmas approaching, one cannot help but see a lot of Santa Clauses around with rosy cheeks and "full" figures. They do project happiness and wellness even though their vitals and blood works may be off. Italian mothers(-in-law) would certainly prefer their sons (-in-law) or daughters(-in-law-) to look more like Buddha then JC, and feed them accordingly, although they diligently pray to the latter.

I guess one could define health as having normal blood work, normal vitals, normal BMI, and no complaints, or in a nutshell somebody who need not go to the doctor. Whereas wellness can be defined as being happy, comfortable in one's skin, full of energy and positivity and well-adjusted to society and to one's environment. There are many reasons behind those rosy wellness cheeks and some are not considered healthy, e.g. alcohol intake. Surely many healthy people are also "well" and vice-versa so as usual moderation is the answer and the truth resides somewhere in the middle.

With people living so much longer, emphasis is no longer just on health but certainly more and more on wellness. The latter is considered is a key ingredient in the quest to remain healthy, meaning not needing to see a doctor. The wellness armamentarium is very vast and expanding every day.

In 1990, with Dr Mathew Lee, head of the Rusk Institute, we testified before the US Senate about the beneficial effects of MUSIC on AGING and the elderly. How Music decreases depression, enhances sleep and content n this population, and also in severely disabled patients like the residents of Goldwater Memorial in New York City. Music Therapy studies showed how music enhanced the immune system of patients with Crohn's disease among others. Simple wellness tool, very cheap yet quite beneficial.

Asians have always been very creative regarding wellness and well-being, maybe inspired by Buddha and his representation. Acupuncture is one of their tools but it involves sticking needles which is invasive. Feng Shui on the other hand is gaining a lot of momentum not just in the East but also in the West. It is not invasive at all as it endeavors to rearrange your environment primarily and your outlook in relation to it. It is like self-administred psychotherapy, based on numerology and anchored in reality and real objects, such as homes, location, furniture placement, etc.  I was recently told the number 4 is very bad in Feng Shui that is why in Hong Kong buildings do not have a 4th floor. Of course in the west, buidlings often do not have a 13th floor but guess what: 1+3 = 4 and we are back to number 4. Of course my street address is number 4. I should have known before I moved in and prevented a lot of aggravation. It could have been a key to my wellness. There are remedies that can be used after the fact. Thank God!

I do not know about you but I know a large number of people who believe that wellness is attained via vitamins and supplements and they take a huge variety of those daily. Whether they have chronic arthritis, diabetes or obesity, or whether they simply refuse to age, they start swallowing these with a vengeance  in their forties. The problem is that these supplements are of variable quality and the pills are very erratically absorbed in the intestine, thus unpredictable bio-availability, and not very gentle towards it. So popping these pills may not have the expected effect. Better take one LIQUID supplement  daily containing all the possible nutrients, from a known US manufacturer. Liquids are much better absorbed and quickly bio-available. In this wellness category, we can place Bio-identical hormone replacement which is often essential in that same age  group and would affect energy, mood  and well-being but also libido, cardiovascular health and cancer prevention (refer to Pillpopper and PharmaEconomics blogs)

Of course as a wellness corollary we have the various exercise regimens out there: Pilates, bar method, spinning, aerobics, calisthenics, Yoga, etc. This is again ANOTHER CHEAP WAY to stay fit, healthy and also happy (via the endorphins secreted).

In conclusion, through Arts, Feng Shui, Nutrition and Exercise, focusing on Wellness is cheaper, more fun and more rewarding. For one it would make Health much less of an issue!

Is Being Healthy more Patriotic?

The answer is really YES and NO. I will explore some scenarios with you and you be the judge  If a citizen is healthier s/he would be costing a lot less money to the healthcare system in the first let's say six decades of life but s/he will also live longer thus costing more money later in life in social security benefits and eventually healthcare. If we live long enough we will all have to take a bite of healthcare sooner or later, i.e. arthritis for one will always set in as long as we have to deal with gravity which we do on planet Earth.

Recently a radio talk show host presented the dilemma of the tobacco taxes and their impact on the Treasury. The taxes do inject sorely needed cash into the government coffers but they could also work as deterrents: either people will buy their cigarettes abroad or on Indian reservations, or they would stop smoking altogether because they can no longer afford it. In both scenarios, those tax revenues will slowly but surely dwindle, the higher the taxes the faster. However those who stopped smoking will live longer thus costing a lot more money later on in their life. A good accountant would tell you that these tobacco taxes may end up costing a lot more than they bring in. Another unintended consequence of a government program (refer to CMS blog 12/3). The cynic could deduct in this instance that SMOKING IS INDEED PATRIOTIC (pays tobacco taxes to the government and kills you sooner so you are less of a burden). The Europeans understood that long ago that is why you do not see a ban on smoking there!

I can definitely say that artificially induced multiple births are not very patriotic to say the least, especially when you think of the OCTOMOM and similar stories. As you know IVF is now common practice, much more successful than when I was going through it in the mid 80s, yet still quite expensive and not covered by a lot of carriers (which I agree with). So when a couple has more than one viable embryo, they usually ask the doctor to implant both to cut costs and be done with it. Sometimes patient and doctor agree to implant a bunch and that I think is non-patriotic. We know that the more fetuses are in the wom, the more chance there are that one or more are premature and/or have health problems that will end up costing society millions of dollars after birth and sometimes throughout the child's (children's) life(ves).  These medical prowesses may illustrate scientific progress but also lack personal responsibility and accountability on behalf of the couples involved AND their doctors. This is all the more true as there a millions of orphans patiently awaiting to be adopted and that would be patriotic.

Borrowing a rubric from Bill O'Reilly's show, I would call these multiple birth doctors pinheads not patriots. 

In a nutshell, as long as you can afford it and pay for it, whether it is smoking or having triplets, than you are not unpatriotic. When you want everybody else to pay for it, that is a different story. That probably gives us a bird's eye view of how these healthcare boards (otherwise depicted as death panels) will operate in the near future: WOULD PATRIOTISM BE THEIR LITMUS TEST?

Dis-Ease v. Disease

It is quite common to confuse dis-ease with disease, the former describing a state of malaise, discomfort anxiety, the proverbial sick to my stomach status or complaint. It utilizes the word sick yet it is not a true disease state by medical standards. Often these complaints are real and the subject, frustrated from not being taken seriously, seeks validation by working the symptoms into the closest disease state they can think of. It is common knowledge that some diseases and medical conditions lend themselves better than others to these psychosomatic signs and symptoms, i.e. ulcer disease, back pain, auto-immune, some cardiovascular manifestations, etc.

Chronic Pain is one of those very broad continuum dis-ease/disease conditions that is very common in western societies where billions of dollars are spent to treat it...usually badly and/or too much. The condition is barely acknowledged in the Eastern majority of humanity. That should help prove my point.

Back pain is one of the leading causes of chronic pain, in part of course because it often leads to monetary compensation and that is an incentive to keep treating (I refer the reader to my previous blogs). I have always told my patients that chronic pain is like a Greek Medusa  with multiple heads: you have to kill them all, if not individual heads will keep growing back. The heads can be described as follows: 1) source transmitting the pain signal, e.g. disc; 2) spinal cord wind-up and transmission: 3) cortical interpretation, amplification or inhibition; 4) emotional overtones (anxiety, depression, bipolar); 5) environmental and societal factors, i.e. spouse, children, finances; 6) extrinsic factors - secondary gains (WC, PIP, SSDI, legal case, etc.) to name the main ones. Factors 1 and 2, possibly 3, rarely 4 can be considered disease but the others are dis-ease. 

These "heads" often interact with each other. For example, I had a woman patient whose back pain increased (1) every time she had a fight with her son (5) until she decided to have him put in jail and her pain improved. Another patient's neck pain was well controlled with mild narcotics (1). Suddenly it got a lot worse and after insistent questioning she admitted that her father just died (4) and that made her "pain" unbearable. More narcotics in this case would replace getting liquored up at the neighborhood bar to forget. Sometimes the interaction is more sordid and manipulative but no less tragic: exaggerating pain complaints (1) to sell the drugs and derive some income (5). Of course more complex interactions happen all the time and chronic pain patients usually warrant expensive polypharmacy regimens to treat factors 1 thru 4 at least. The other factors are societal and behavioral, very real yet beyond the doctor's reach.

My good friend Dr Rinoo Shah, in a November 2012 SPINE editorial, points out very scholarly how spine pain classification is nothing but guesswork, varying with time and between providers. This certainly should prompt us all to be as little invasive and as much patient and conservative as possible regarding this very mercurial yet very costly condition. The simple reason is we never really know what head of the Medusa we must treat or we are actually treating...and since we have to try to kill them all, this can never be achieved with the scalpel alone. In a nutshell, Dr Shah describes it as a moving target, try treating that in the O!

Dr John Sarno, a now famous NYU professor and author, successfully treated a large number of people, including celebrities by advocating a Mindbody Prescription (1998), in essence Detreating Pain, via seminars and books, no drugs or heroic procedures. Several times, when a patient's pain stopped making any sense, I gave them his book or sent them to him and that did it. This also proves the point I made above that we are treating pain in this country badly and too much.

The best remedy is prevention, is to focus on treating the dis-ease to avoid it morphing into a disease and sprouting into a Medusa. WELLNESS is a great tool that is being utilized more and more although not early enough in most cases, simply because INSURANCE DOES NOT PAY FOR IT. I believe health insurance should stay out of that business and should be limited to catastrophic occurrences but that was the topic of another blog. Wellness has exercise as a corollary and personal responsibility as an engine. Having a third party pay for it defeats the whole purpose.

I remember a statement that applies here, from a psychiatrist friend of mine:

"Half the treatment is paying for it!"

Disability Loves Company

Under this rubric, a Central New York couple comes to mind. They were in their thirties, the man a bit younger. He was the registered patient consulting for a back injury on the job. Right of the bat I realized that he was taking too many narcotics and nothing curative was being proposed to him. As I usually do in these circumstances, I tell him if he wants to be my patient I have to wean him off his current narcotics first and then perform the minimally invasive spinal procedure that seemed indicated. Doing the latter while he was still on so much narcotics would be like pouring oil on a fire and it would only aggravate his dependency. He seemed to vaguely understand despite the edginess bordering withdrawal but his wife objected to the change of medications! It turned out that she was the one running his show and, after some digging. I found out that she got on Medicare in her early thirties because of an "unspecified" mental illness (refer to my CMS blog of dec 3). She was very concerned that her husband keeps his medications because IT WAS OBVIOUS SHE WAS THE ONE TAKING MOST OF THEM. Never mind that narcotics are not the treatment of choice for any mental condition, his WC coverage paid better for the drugs than her Medicare plan. The morale of this story is the "loving" spouse opposed any curative procedure for her husband's injury so that he keeps getting the drugs that she craved. I only saw them once.

Over the years I have noticed that, especially in younger couples, when one gets on the disability rolls, the spouse does everything s/he can to emulate. Soon their progeny follow their role model of course and the cycle goes on. I guess it may start sort of like that: "honey, you have to do the dishes and take the garbage out because I am disabled you know" and pretty soon we would hear the fed up and exhausted spouse finally being able to retaliate: "oh yeah! Me too so there...get off your lazy ass now. I have done it long enough".

This all too common scenario is really too bad. It may start off with a loving caring and hard working spouse with an actual job, who slowly feels jilted and taken advantage of to the point that s/he endeavors to get on the dole him/herself, in any number of ways, just to get vindication and stop the abuse. Before you know it the entire household is on the taxpayer's dole.

Of course I am not describing here severely disabled individuals but more like the Ford dealer's customer in yesterday's blog. The only way to stop this catch 22 is to shorten the disability period at all costs by rigorously enforcing the 1988 law for example (my CMS blog of Dec 3) or a tougher one.

Time-honored statistics have shown that if somebody has been out of work (disabled or not) for a year or more, their chance of ever returning is only 25%!

This reminds me a vignette I saw in a small shop in Picadilly Circus during my very first visit to London in the 70s:

How Wonderful it is to do Nothing and to Rest Afterwards!

Dependency 360 is sadly NOT another CNN show

My good friend and long-time patient Joe E from Buffalo, NY emailed me this anecdote a couple of days ago that I find quite enlightening:

A Ford Dealer from Latham Reports this true story: "One of my salesmen here had a woman in his office yesterday wanting to lease a brand new Focus.   As  he was reviewing her credit application with her he noticed she was on social security disability. He said to her you don't look like you're disabled and unable to work. She said well I'm really not. I could work if I wanted to, but I make more now than I did when I was working and got hurt (non-disabling injury). She said the gov't sends her $1500.00 a month in 1 check. And she gets $700.00 a month on an EBT card (food stamps), and $800.00 a month for rent. Oh yeah, and 250 minutes free on her phone. That is just south of $3500.00 a month.When she was working, she was taking home about $330.00 per week. Do the math and then ask yourself why the hell should she go back to work."   

This attitude and should I say "way of life" is quite pervasive in 2012 America. You all heard on the news about the lottery ticket winner who staid on food stamps. As a doctor in NY and NJ I have known for years that patients made more tax-free money on disability and/or workers compensation than actually working. Where is the incentive to see the glass half full?

Even fresh immigrants or refugees figure out this version of the American dream right off the boat. It is almost as if it is inscribed in the visa papers they have to complete at the consulate prior to coming! I remember in the late 1980s I was a resident in a hospital in Brooklyn and there was an influx of jewish russian refugees so we were interviewing some of them to try to employ them in some capacity. One guy who spoke good english said he was a psychologist and I grinned because we could always use one of those in rehabilitation. He was only one week in the US yet he made it very clear to me that it will have to be off the books or else he would loose his Medicaid status. My grin disappeared. I have encountered similar behaviors among the bosnian refugees in Utica. Being on the dole was kind of a way of life there. in socialist Yougoslavia,  so they were longing to reproduce it here. 

From NJ Governor Brandon Byrne's perspective and famous say: "I never met a piece of glass I did not like", a glass half-empty is a call to arms, a rallying cry, screaming to be filled. Hence the other 180 degrees of the Dependency circle, this half is not societal or financial, it is chemical in nature, alcohol for the Gov, drugs for others. When these two halves meet it is definitely not the Lion King's Circle of Love, it is more the Hyenas' Circle of Hate.

Indeed the vicious circle of dependency feeds upon itself and gains momentum as it does so like a powerful centrifuge. A physical dependency leads into financial dependency and vice-versa every day of the week. The drug or dole addictions are two heads of the same Medusa: you kill only one the other one laughs at you while the severed one regrows. You have to kill both in unison to decisively kill that Medusa.

This cyclotron of dependency is so self-powered that very soon both drug dependency and financial dependency melt into an all-encompassing dependency addiction.  The subjects of this 360 dependency become addicted to dependency itself. It becomes their raison d'être, their modus operandi. Pretty soon they stop knowing any better and they identify with this way of life. Try reaching out to them then. Try disrupting this vicious circle. You might as well amputate one of their limbs.

The 90 become 180 becomes 270 becomes 360 at an astonishing speed. Witnessing it is like witnessing a patient ravaged by leshmaniasis (flesh-eating bacterial disease).

The rate of this D360 transformation is reaching epidemic proportions and our response to it has been tantamount to throwing some blankets at a brush fire. The answer is in the core of that circle: the more hollow it is the more debris amasses at the periphery and the thicker the crust to cut through. As this goes on and spreads engulfing the nation, I remember a Yogi Berra say:

"the future is not what it used to be"

...and that's putting it mildly!

Penny Wise and Pound Foolish: The Chronic Plight of CMS

Circa 1988, Congress enacted a law that was supposed to revolutionarize the way people get on the SSDI rolls and stay on. Indeed for the first time, disabled persons were going to be rechecked every 3 years and, if there was any improvement, they were to get off the SSDI rolls. Several grants were awarded by the SSA to try to measure this “improvement” as precisely as possible utilizing computerized functional capacity evaluation. I was awarded one such grant. The concept was fine and it was an attempt however feeble to have at least younger disabled individuals, e.g. failed backs and necks, weaned off the government rolls.

Here is the glitch: there are a handful of diagnoses, we will call them GROUP I (often the oldest group), that get you onto SSDI almost right away or no longer than a few months after inception, quadriplegia, paraplegia, stroke, amputation, multiple sclerosis, ALS and the like. These diagnoses are known to take a long time to improve if at all and usually most people do not recover so why wait to take them on. Their entrance physical into SSDI usually shows very poor function, way less than 100%.

Then there is the vast array of orthopedic or musculoskeletal diagnoses like back and neck pain, fibromyalgia, various arthritic conditions, etc (GROUP II). By the time these guys qualify for SSDI (12 months), they are usually functioning quite fairly and they have by and large recovered from that back surgery or knee replacement. So their SSDI entrance physical, to which they usually drive themselves, routinely, shows acceptable ranges of motion albeit not 100%. Yet they qualify because of pain comorbidities and other factors.

Finally there is another vast array of claimants with even younger candidates who suffer  mental disorders, like depression, anxiety, bipolar, etc (GROUP III) Physically the latter group is usually quite highly functional and their true objective findings can be few and far between,

Here is in a nutshell the major unintended consequence of this law: Many patients in group I, although the most severely afflicted, usually get measurably better in the first 6 months, especially amputees, stroke and multiple sclerosis they can go from 10-20% to 60-70% or more in functional capacity. The verdict is they have improved so they are off the rolls even though quite severe conditions.

Patients in group II were already at 80-90% function when they came into the system. That is a virtual 100% so how to measure and document the improvement required to get hem off? very difficult so they stay on and on. Patients in Group III (the mental ones) are the hardest to document improvement so once in the system they stay forever and remember they are the youngest so forever means literally that.

Since this law was enacted, the number of SSDI recipients has now doubled to approximately 9 million and they are younger and younger (meaning longer and longer support).  Of course all of them eventually get Medicare coverage within 1-2 years and we wonder how this program is practically bankrupt.

Other examples of CMS paradoxical decisions to mention just a few: They still do not support minimally invasive spinal surgery and force patients out of the much cheaper (more efficient, less infection risks and comornidities) surgical centers into the hospitals. They would pay $10,000+ for a below-knee prosthesis and only $500 for the amputation itself. They pay more for the EMG test to diagnose carpal tunnel syndrome than for the surgery itself, and so on and so forth.

Perhaps the most egregious is the abuse of spinal stimulators for back pain, which do not cure the problem but simply run interference with the spinal cord pain message transmission. Indeed the cost of this gizmo reaches close to $40,000 (25k for the battery and $400 per lead for trial and permanent, usually up to 16) and the patient is lucky if it works at all beyond 1 year. During the trial the patient is laying still supine in the OR and you can program the device to your heart's content. He says he feels good so he is up and about and starts moving around. Actually he may start doing more and more activities he desperately wanted to do for a while but could not because of pain and its resulting stiffness. After a while, due to this increase in movement and activity, the leads which are supposed to hug a certain level of the cord, are displaced and the patient starts feeling pain and strange sensations in various non-targeted areas of his body, stomach, ribs, etc. So the rep is called and tries to reprogram once, twice and then gives up. It is doomed proposition because either it barely works thus the patient does not move much and the leads stay put or it works well initially and the patient becomes a dare-devil, the leads move a bit and the device fails. Results too weak to justify such expenditure, usually from CMS.

In general, doctors suffer the most from low Medicare rates and many of the best ones do not want to see those patients because they cannot afford to. Hospitals pan out well because they have strong lobbyists and some are involved in educating residents and medical students so they get more funds. Besides, whatever the hospitals loose out on in OR and procedure fees they make up in added tests, hospital stays etc. For more than a year now there is a 27% cut looming in Congress for physicians Medicare fees. When will the other shoe drop? only a matter of time.

It is frightfully easy for the fixed-income octogenarian Medicare patient who receives a patient responsibility bill in the mail from the physician’s office (usually 20%) to call the fraud hotline stating: “I never saw this doctor before!”. Indeed memory is not the best attribute of this elderly segment of the population and they could unwittingly (or not) make a perfectly innocent doctor the target of a bona fide witch hunt. The Feds would not need much of an invitation since the government is in a trim fraud and abuse mode and doctors are such easy targets, some even with money to reposess.

Most doctors do not even want to bother and they send these senior patients to the hospital instead, thus costing the system a lot more money (Penny-wise pound-foolish). Doctors should be considered part of the solution not the problem. Just before 9/11/01, I was told that doctors where deemed public enemy number one and CMS was going after them right and left for fraud and abuse and happily collecting mucho dineros for the government coffers in the process. Then "luckily" terrorism took their place as public enemy numero uno and doctors had some respit for about a decade. Now the pendulum is swinging back.

Doctors are the gatekeepers of healthcare, if pushed too hard they may leave these (flood) gates wide-open and seek greener pastures.