CHAPTER 6
PROGRAMS FOR ELDERS AND DISABLED
“Some people, no matter how old they get, never lose their beauty - they merely move it from their faces into their hearts.” - Martin Buxbaum
§ 6.1.0 LIFE EXPECTANCY
§ 6.1.1 Life expectancy can be looked at by age the age of the person in question. At birth a male child might be expected to live to, say 74. At 30, after he has survived the dangers of the first year and teenage “foolishness”, he ought to live longer, another 48 years, or 78. If he has lived to 70, having survived many fatal illnesses in his 50s, he ought to live even longer, another 10, or 80. If he lives to 79, he ought to live to 84. And so on.
§ 6.1.2 At birth, Americans are expected to live about 5 years less than people of other OECD nations! That difference might not sound like much to a 20 year old, but, that difference means a lot to a 75 year old!
§ 6.1.3 This is interesting. While we live an average of 5 years less than others in OECD nations, at 65 Americans are expected to live about as long. So, if we can get through infant mortality, teenage foolishness, and heart disease, we’ve got a chance of outliving others.
§ 6.1.4 At 80, Americans are expected to live longer than people from all but two other OECD nations (the ones that conservatives point to as providing poor quality of care).
§ 6.1.5 I interpret this to mean any combination of:
· US health care is much better for elderly than youth (certainly infant mortality is higher). As such, perhaps more time ought to be spent in college, health care provider / medical school, training, and Continuing Education Programs on care in pediatrics and youth.
· The longer a cohort of Americans survives, they are better at self-preservation than foreign peers.
· Americans are at greater risk of death in earlier years, due to poor neonatal care, poor pediatric care, teenage auto accidents, drug overdose, homicide, suicide, and related conditions (e.g. trauma death secondary to DUI, MI secondary to not exercising or poor stress management or using cocaine), heart disease, and diabetes.
· There are risks to which we endanger our children to which elders were not exposed such as carbonated beverages, processed foods, toxins, pesticides, preservatives, etc.
§ 6.2.0 QUALITY OF LIFE (QOL)
“Wrinkles should merely indicate where smiles have been.” - Mark Twain
“And in the end, it's not the years in your life that count. It's the life in your years.”
§ 6.2.1 More study, cost comparisons, even individuals who decide on treatments must address QOL.
§ 6.2.2 Why should we live if only in pain or misery? QOL must be addressed each time health services are offered and that address ought to be documented, even if only checked off or a QOL concern was addressed.
§ 6.2.3 I believe that health provider education and training as well as Continuing Education Programs must address QOL. Likewise, QOL ought to be factored in a payment system. The more improvement or less decline in QOL, the greater the “bonus” payment.
§ 6.3.0 SUICIDE
“Suffering is a gift. In it is hidden mercy.” - Jalaluddin al-Rumi
§ 6.3.1 Why does the US have such a high suicide rate? Isn’t that a critical issue that NIH ought to investigate from an “applied” perspective? Elderly suicide is more common than teen suicide (also tragic). Why? Reduced QOL. Elders are more likely to be alone, not have a job, have reduced contact with their children, have poorer health, be less able to do things they used to do, and suffer grief. White men feel the greater shift from power to impotence than others and are most likely to commit suicide.
Some concerns of aging are nicely expressed in Lennon and McCartney’s “When I’m Sixty-Four”:
Will you still need me
Will you still feed me
When I'm sixty-four?
§ 6.4.0 ELIGIBILITY AGE FOR MEDICARE & SSA
§ 6.4.1 The 2 year graduated increase in eligibility age for SSA and Medicare enacted during the Reagan Administration did not approach the increased longevity we’ve enjoyed since the 1930s and 1960s, when SSA and Medicare were legislated.
§ 6.4.2 The eligibility age must again increase. Let’s say that Americans, government, providers, and companies work together so that the average life expectancy increases 5 more years. In that case, we might need to extend the eligibility age 3 years to 70. This would reduce SSA and Medicare costs by $132 B a year. It would increase revenues (taxes during the extended three years) by $48 B a year. Actually, as costs would include the additional two years, we would see the net effect of a modest increase in SSA and Medicare costs. Interestingly, as the age of eligibility for SSA increases, the number of applications for SSD increases.
§ 6.4.3 If government research, prevention programs, and disease management helped me live 5 years longer, as in those “socialized” OECD nations, I would gratefully accept a 3 year postponement of SSA and Medicare.
§ 6.5.0 EXPAND TRADITIONAL “MEDICARE”
§ 6.5.1 SSA ought to automatically notify individuals of SSA, SSD, and Medicare eligibility or potential eligibility.
§ 6.5.2 Medicare ought to cover the disabled immediately, rather than making them wait for 2.5 years before they are eligible for Medicare. During those 2.5 years, the disabled are often without insurance and we as a society are failing to care for the most needy among us. Most applications for Disability are initially rejected, but, with continuing appeals, and expensive legal costs incurred by unhealthy, uninsured, poor people, SSD begins. The costs of legal maneuvering and procedures cost Bs of dollars each year that could be invested in caring for the disabled. Once centralized EMRs are developed, reviews can be performed expeditiously with all information available. Actuarial reviews can be conducted to determine in advance individuals who are likely to be malingering or in need of services, and decisions can be made quickly. I suggest that SSA pay the 25% or 40% of legal fees incurred by the disabled who appeal SSA decisions but who ultimately win judgment in their favor.
§ 6.5.3 Cover Medicare Part B at same time as Part A.
§ 6.5.4 Home Healthcare (HHC), Halfway Houses (HH), Assisted Living Facilities (ALFs), and hospice must be covered by mandatory public, private, and not-for-profit long term care insurance, including an expansion of coverage and public payments that are competitive with the private sector. The relative savings these programs provide over the most costly options must be calculated and used in determining payments and coverage.
§ 6.5.5 Nursing homes (NHs):
§ 6.5.5.1 - NH payments are 3% of health care expenses for 1% of the (most needy) population. Their not being in a NH would often result in a family member not working and providing care 24/7. Residents of NHs have the potential to be cared for more thoroughly.
§ 6.5.5.2 - CMS must cover NHs beyond 90 days. As I elsewhere propose that costly, inefficient, ineffectual Medicaid be absorbed into the federal public health insurance system, essentially the same way that I propose that private and non-profit insurers be permitted to compete across state lines. As Medicaid often provides (insufficient) coverage for NH care beyond those 90 days, some of the “added” cost of coverage is already being provided by state Medicaid programs.
§ 6.5.5.3 - The average NH stay could be reduced from 2.4 to 1.2 years if Medicare covered alternative service providers and it were to use actuarial decision making systems.
§ 6.5.5.4 - NHs must have a geriatric NP, PA, or geriatrician coordinate care for the elderly or infirm within each NH (or HH, ALF, hospice). This would be less costly and more efficient than a dozen part-time MDs. And, it would improve continuity of care for each patient. As suicide and MI are elevated among seniors, geriatrically trained MI providers ought to offer care within each facility.
§ 6.5.5.5 - Public payments must authorize the full cost of care. This makes providers in underserved regions (where 80% of patients are on public insurance) file bankruptcy. It makes insurance companies pay higher fees to cover lower fees of public programs. It would allow NHs the resources to offer quality, personal services, and it will reduce medical errors and litigation.
§ 6.5.5.6 - Once public payments are competitive and standardized, perhaps adjusted to cost of living like federal employee wages, higher service standards must be introduced into NHs. Some QA violations might be
criminalized. I would argue that in many cases, with the low reimbursement rate provided, poor quality of care is complicitly acknowledged by third party payers at this time.
§ 6.5.5.7 - NHs that are more reliant on Medicaid (meaning much less money) provide lower quality of care and services for the elderly and infirm. It is the elderly and infirm who ultimately pay the price of low Medicaid payments, usually through pain, less supportive care, lower QOL, and earlier deaths.
§ 6.5.5.8 - Low reimbursement rates are immoral. While one study reported public rates of $3,600 less per patient a
year, I calculate the average difference at $15,000. They don’t include write-offs.
§ 6.5.5.9 - Insurance and legal costs are bigger parts of NH budgets than they were a few decades ago. This reduces what’s left for resident care.
§ 6.5.5.10 - Lawyers bring justice for residents in NHs that are paid unconscionably low fees by insurances.
§ 6.5.6 Opponents of reform cite that Medicare costs one-third more per patient than private insurance. That is true. But, think a moment - Medicare covers the oldest and disabled, nor does it exclude pre-existing conditions.
§ 6.5.7 Medicare provides a very modest death benefit of $250 a year to help with funeral expenses. Frankly, that amount of assistance is as much annoying as it is helpful for individuals who have sufficient savings. On the other hand, it is invaluable to those with insufficient resources. I think that the “death benefit” ought to be increased from $250 to $4,000 but that eligibility criteria be calculated from the previous year’s tax returns.
§ 6.6.0 COMMUNITY ELDER’S PROGRAMS
§ 6.6.1 We must provide funds for elders with low income and health conditions to return to family. Being near family allows closer monitoring of conditions, improves QOL, increases longevity, and reduces short term costs. I estimate that this program would cost $2 B a year but would save $8 B a year in NH and home health care.
§ 6.6.2 Community aging recreation centers, elder care, and respite programs are essential for elders and families providing care but who need to work or take a vacation. This reduces NH costs, decreases the retiree to worker ratio, and strengthens Medicare and SSA. Geriatric care specialists and perhaps consultations with geriatric medical providers could provide elders and family members timely, objective feedback that improves care, QOL, extends longevity, and reduces short term health costs. Some costs of such programs might be borne by employers, caregivers, the senior, or state / municipal governments. I project that community elder’s programs would cost $75 B a year, others would pay $50 B and the federal government would pay $25 B a year. Savings would be $112.5 B a year. Infrastructure investments of $6.0 B a year would be required and savings of $2.0 B would be realized.
§ 6.6.3 These critical programs are not always offered in rural communities or in states that do not recognize the value of these programs for seniors. I propose that the federal government provide or mandate these programs throughout all communities of a minimum size.
§ 6.7.0 INCENTIVIZING WORK PROGRAMS FOR THE DISABLED & ELDERS
“Anyone who stops learning is old, whether at twenty or eighty. Anyone who keeps learning stays young. The greatest thing in life is to keep your mind young.” - Henry Ford
§ 6.7.1 Most of the disabled or elderly like to work.
§ 6.7.2 Continued flexible work is associated with better mental health and longevity.
§ 6.7.3 Many “disabled” / elders can volunteer / work PT with special accommodations.
§ 6.7.4 Many people with SSA / SSD / Medicare fear losing eligibility, so, they do not get a part-time job and contribute to society, where they could. Programs ought to assure that those who earn a limited amount will not lose benefits.
§ 6.7.5 Such programs could increase GDP 2.5%.
§ 6.7.6 I propose that senior citizens be permitted to register for classes in public universities and community colleges at a reduced cost of 50%. Federal programs might subsidize seniors-return-to-school programs at a cost of $3.0 B a year. These programs would improve MI and health of seniors. Savings would be $1.5 B a year.
“Give a man health and a course to steer, and he'll never stop to trouble about whether he's happy or not.”
- William Shakespeare
§ 6.8.0 PREPARE A LIVING WILL & ADVANCED DIRECTIVES
§ 6.8.1 Transition to retirement can be difficult, as we’re often unprepared for the changes to health, loss of
friends and family, lost identity, suddenly spending more time with our spouse. In order for me to donate organs, I prepared a living will and advanced directives. I strongly advocate that people ought to take control of their lives and deaths now so that some bureaucrat sitting in his executive suite in Hartford, CT (or Washington, DC) doesn’t seal my fate. I recommend that at retirement or prior to obtaining SSA, everyone ought to view (internet) videos dealing with successful coping following loss, grief, marital changes, purpose, financial planning, medical changes, spirituality, legal planning, and preparing a living will and advanced directives. Insurance ought to cover retirement transition counseling for a brief period of time.
§ 6.8.2 A living will and advanced directives ought to be prepared in private. If you have special requests, you ought to inform your doctor, hospital, family, lawyer, clergyman, people who are in a position to assure that your wishes will be honored. The government or private insurance bureaucrats ought to be completely uninvolved.
§ 6.8.3 While preparation of a living will and advanced directives is great for retiring people, frankly, it ought to be completed by everyone, especially those who have family who have died young due to disease, those with chronic or terminal diseases, those who have particular requests guided by their religious beliefs or philanthropic / scientific motives.
§ 6.9.0 DISABLED GETTING TREATMENT
§ 6.9.1 The disabled must obtain medical treatment for conditions that prevent them from working (assuming insurance is accessible to them). As it stands now, once someone obtains disability, they do not have to obtain treatment for the disabling condition that made them eligible for government assistance. Many conditions for which people are on disability can be treated and the person can return to the work rolls.
§ 6.9.2 People effectively treated must return to work. This could reduce SSD rolls by 500,000 (8%). I estimate that this could save SSD about $6 B a year and this could save Medicare $5 B a year.
§ 6.10.0 PURGING THE DISABILITY ROLLS
§ 6.10.1 Between ‘90s Welfare Reform and hopelessness from un- and under-employment due to Free Trade and Global competition, there has been a marked increase in applications for SSD in recent years.
§ 6.10.2 While 1/3 of SSD applicants feign symptoms, 11% might not be eligible for SSD who are on it.
§ 6.10.3 Regular and periodic examination of disability rolls and removal of individuals who do not need to be on it could result in significant savings.
§ 6.10.4 If the SSD rolls were reduced by 4%, SSD would save $3B and Medicare would save $2.5 B.
§ 6.10.4 This program is vital for helping society’s most needy. Temperance ought to supersede vigilance.
§ 6.11.0 HOSPICE AND ALTERNATIVES
“I don't want to achieve immortality through my work; I want to achieve immortality through not dying.”
- Joseph Addison, Cato, Act V, Sc. 1.
§ 6.11.1 Hospice provides dying Americans with dignity and respect that we all deserve.
§ 6.11.2 We, Americans, are referred to hospice much later than are patients from other OECD nations.
§ 6.11.3 The determined spirit of American medicine must be praised. But, it does not translate to better outcomes.
§ 6.11.4 Depriving hospice often denies the chance for that person and family of coming to terms with death.
§ 6.11.5 End of life care costs $700 B a year ($140,000 for the average dying person), just so that we can extend life a few days to months. Advocates of end-of-life super-spending point to the fact that nobody knows when somebody else is going to die. In fact, most people can quite accurately predict the imminent death of one-third of this population. If Do Not Resuscitate orders exist, then super-spending for those people ought to not be pursued. By reducing to one-half the super-spending upon one-third, US health care spending would be reduced $114 B a year.
§ 6.11.6 One study found that the dying would spend everything to live a short while longer amongst their families. The price of life is, well, priceless.
§ 6.11.7 Referral of the terminally ill 2 weeks earlier to hospice could save tens of Bs of dollars a year and enhance QOL.
§ 6.12.0 RESEARCHING MEDICAL TREATMENTS SPECIFICALLY FOR OLDER AMERICANS
§ 6.12.1 How many Tylenol can an adult take? How many if 85? What if she takes medications that impair liver function? How can we enhance understanding doctor’s directions? More and better clinical research must be conducted on the efficaciousness of treatments specifically upon elders.
§ 6.13.0 SAVINGS AND ENHANCED QOL THROUGH END-OF-LIFE MEASURES
§ 6.13.1 Statistical / actuarial decision making programs may help patients, their loved ones, and their physicians to make better informed decisions.
§ 6.13.2 Everyone ought to have prominent living wills informing of their wishes in case their life ends tonight. It is frightening to think of our own mortality, but, it makes it a bit easier when we have faced death and gone ahead and wrote out our will, living will, advanced directives. Our wishes must be prominently displayed. We can change our minds anytime. This is for the patients’ benefit to assure that their wishes are respected. Frankly, sometimes, if a person’s wishes had been written down, doctors could honor those wishes but instead must proceed with heroic measures that cost Americans hundreds of Bs of dollars each year.
§ 6.13.3 Medical heroic measures not efficacious ought to be more rigorously examined.
§ 6.13.4 I believe that individuals facing end-of-life decisions ought to have available to them the services of bioethicists and spiritual counselors. These services ought to be covered by public, not-for-profit, and private insurance.
§ 6.13.5 Psychiatric and psychotherapeutic services can be beneficial for people with dementia / AD. Analysis of their capacity to consent to treatment may be needed or assessment of cognitive functions especially in order to identify strengths for caregivers to use to manage behavior. Behavioral management assessment helps caregivers. Being respected and listened to is helpful and calms patients with dementia. Services ought to be provided for family members to help them cope and manage effectively.
§ 6.14.0 MEDICALLY ASSISTED SUICIDE (MAS)
FOR THE TERMINALLY ILL IN PAIN
§ 6.14.1 I shutter to think, a future government bureaucrat deciding whether I ought to be put out to pasture because the cost / benefit analysis says that I’ll be more of a burden than benefit to society. I equally shutter to think of a bureaucrat in Hartford, CT deciding whether or not I ought to be put out to pasture because he needs a $50,000 bonus to send his child to college.
“To save a man's life against his will is the same as killing him.” - Horace
§ 6.14.2 My dad pleaded to die at the end of his life. People with a loved one in pain, pleading to die struggle between laws, ethics, siblings, church codes, beliefs in the afterlife, bills, satisfying the loved one’s wishes, and, our own desires, either to hold on indefinitely or end the suffering. It’s something that I carry with me every day.
· Having the option of MAS might be of comfort for those with painful terminal illnesses.
· MAS must never be mandatory but ought to be an option selected by the person, physician, and survivors.
· Bioethical consultations ought to be mandatory, spiritual counseling of the patient’s choice ought to be optional but it also ought to be a covered expense, both services ought to be covered for the terminally ill with reasonable maximums.
· MAS could reduce end of life pain, family angst, and bankruptcies.
· MAS must never be used as a financial tool.
CHAPTER 7
WOMENS PROGRAMS
“More countries have understood that women's equality is a prerequisite for development.” - Kofi Annan
“Pride and dignity would belong to women if only men would leave them alone.” - Egyptian Proverb
§ 7.1.0 WOMENS’ PROGRAMS
§ 7.1.1 All women would have access to free preventive care offered by Federal Health Clinics, including mammograms, cervical cancer exams, screening for heart disease, dementia, and depression.
§ 7.1.2 FHC programs ought to include comprehensive care for Obstetrics and Gynecology. Infant pediatric specialist consultation would be available through specialists at centers of excellence.
§ 7.1.3 As women compose 54% of the population, more research must be conducted on their health. Separate token programs are satisfying to see, but incorporation into the mainstream of health sciences research is needed.
§ 7.2.0 FEES
§ 7.2.1 Women utilize the US health care system about twice as much as men. Some of that is because women live 6 years longer during the years that are most costly. A second reason is pregnancy. Because of pregnancy, some women’s bodies change and result in increased needs for medical services.
§ 7.2.2 Is an insurance or Medicare premium for women reasonable? They provide a service to society, taking off from their careers to have and raise children. I struggled with this issue, vascillating. I don’t believe that it would be fair to impose a premium based on gender.
§ 7.2.3 Women are not given credit by the SSA for neonatal care and childrearing. I argue that all such activities ought to be credited by the SSA, assuming they had worked in the three years before pregnancy, at a rate of 2/3rds of the average of the previous three years, for a period of up to three years for final maternity and early child rearing. This length of child rearing credit for SSA can be extended for up to 6 years, providing that the person had worked 6 years prior to taking leave. I am not proposing paying for this service. I am proposing that women ought to receive SSA eligibility credit for childrearing.
§ 7.2.4 A partial offset of the increased use clause above is that women live six years longer. As such, they pay six years more in Medicare premiums and co-payments. Due to the six years’ added use of SSA, ought they pay a premium upon SSA, say, instead of 6.20% perhaps assessing a contribution of 7.50% might be argued.
§ 7.2.5 I suggest that frequent consumers of medical services be assessed a premium of 10%. That could include women. I first suggest that further study ought to be conducted on the different medical utilization patterns of men and women. Off the cuff, I’d carve out OB-GYN and Medicare costs for women and not change those. I would examine other services and, if these were found to be abused, I’d be inclined to charge women a higher co-payment (say, $30 over $25) or a higher co-insurance (12% over 10%).
CHAPTER 8
RURAL COMMUNITIES, INNER CITIES. AND OTHER
§ 8.1.0 FEDERAL HEALTH CLINICS (FHCs)
§ 8.1.1 There are FHCs throughout the military and IHS. While not models, they are a precedent.
§ 8.1.2 I propose 2,500 new FHCs. FHCs provide prevention services and work with other agencies.
§ 8.1.3 The FHCs will operate aging centers, elder care programs, child care programs, and ill child care programs. Parents seeking treatment services at FHCs can drop off their children at the clinic’s childcare center while receiving treatment.
§ 8.1.4 FHCs will facilitate providers’ confidential discussions in order to reduce medical errors.
§ 8.1.5 Clinics will provide prevention, primary care, and basic specialty services. They will be staffed with General Practitioners (GPs), Nurse Practitioners (NPs), Physician’s Assistants (PAs), dentists, dental hygienists, geriatricians, OB-GYNs, pediatricians, public health educators, integrated with behavioral specialists. The services that these clinics provide may be billed to third-party providers.
§ 8.1.6 FHC prevention specialists will provide outreach to schools and other public gatherings.
§ 8.1.7 FHCs will provide consultation for safety and disease prevention among those traveling internationally.
§ 8.1.8 FHCs might contract prevention, intervention and treatment services for prisons, school districts, NHs, etc. through such agencies as DOJ, DOE, NIH, NIA, and CDC.
§ 8.1.9 Some specialized consultations might be provided in rural communities by a local PA or NP who consults through IT with a specialist at, say, Johns Hopkins Hospital / Medical School.
§ 8.2.0 PROVIDERS IN UNDERSERVED COMMUNITIES
§ 8.2.1 Payments at 85% of the cost of care for Medicare and 60% of the cost of care for Medicaid are wrong.
Years ago, providers passed along those losses to private insurance companies. Now, private insurance companies set fees, too, usually closer to 100% of the basic cost. So, providers who see a few people on Medicaid provide charity whereas providers in rural communities, in which 85% of patients are on Medicaid or Medicare, ultimately lose money and file for bankruptcy. THAT is why we can’t attract or retain providers in underserved communities. All health care plans must pay competitively. I suggest elsewhere that this will cost the public system $100 B per year. This increase might be graduated to correspond with decreases in other costs to assure a balanced budget.
§ 8.2.2 Impoverished Medicaid patients often must seek distant, less qualified practitioners, or do without services. IT consultations ought to be provided with specialists at a remote location and a GP, NP, or PA at the patient facility and must be reimbursed at a rate that pays for the specialist, the GP, and the IT equipment. Ultimately, this is less costly and provides faster and better quality care for patients. I propose that infrastructure investment will cost $1.2 B a year for 5 years and will save $2.4 B a year for 20 years.
§ 8.2.3 FHCs might sponsor a program in which specialists visit circuits of rural FHCs each month and, alternately, provide telecommunications consultations. This program might also be coordinated with rural MI / SA courts. I propose that this program would cost $300 M a year and save $900 M a year.
§ 8.2.4 Programs that advance moving costs of relocating providers to underserved regions could meet demand. I propose that this program would cost $400 M a year and would bring health care providers to underserved communities.
§ 8.2.5 I propose that by moving people to underserved regions and providing them with sustainable pay, much of the problem with attracting and retaining professionals will be reduced. By incorporating providers in targeted underserved regions as PHS auxiliary officers, instituting a program in which their contributions are recognized, offering IT CEP and consultations, and small stipends, much of the need for 1.3 M service providers in underserved regions will be met. As proposed, this program would cost $4 B a year.
§ 8.2.6 Providers might be encouraged to remain in underserved communities through FHA or a supplemental mortgage program. The cost of such a program, if 1 M providers in underserved regions would be provided mortgages at 2% below market rate for 20 years on a $250,000 home, would be $3 B a year. Purchasing a home and having a mortgage on that home seems to keep more providers in an underserved region than does paying off their student loan upfront.
§ 8.2.7 FHCs could offer supervision for licensure or specialization experience, thus providing incentives for providers to re-locate.
§ 8.2.8 - The federal loan repayment program (NHSC) that is 38 years old is ineffective. It is a lottery that does not provide incentive for the many health care providers who never are awarded tuition repayment even after they have incurred the expense of moving to an underserved region and setting up their practice. I propose that the NHSC become part of PHS and oversee the above programs.
§ 8.3.0 PREVENTION, SCREENING & SERVICES
§ 8.3.1 Everyone ought to be provided free preventive care, wellness visits, annual check-ups, vaccines, and basic treatment, whether public, not-for-profit, or private insurance, in an FHC.
§ 8.3.2 Women ought to be provided free mammograms, gynecological exams, and exams for cervical cancer and men ought to be provided free procto-colon examinations, with frequency based on age and risk. Screenings for cognitive decline, vision, diabetes, melanoma and other cancers, depression, anxiety and stress, hypertension, high cholesterol, abuse / domestic violence, addiction, speech and auditory services will be provided as needed.
§ 8.3.3 As suggested, these programs would cost $75 B a year and save $75 B a year. Prevention, screening, and early detection programs are expected to save on the need for and cost of aggressive, later treatment. I estimate that one-fourth of these services would be provided within FHCs.
§ 8.4.0 CONTROLLED SUBSTANCES
§ 8.4.1 Regulation of controlled substances ought to be modified so patients see the doctor monthly for the first year (as is currently); then bi-monthly for the second year; and then quarterly for the third year and thereafter.
§ 8.4.2 This would reduce visits to physicians by 20 million per year, saving $1.8 B a year.
§ 8.4.3 Advanced check-ups could be performed by NPs and PAs, saving several hundred million dollars a year.
§ 8.4.4 Law enforcement can be satisfied with greater direct access by reviewing EMRs to assure that no physician is prescribing too many controlled substances or that no patient is doctor shopping. Actually, costs of law enforcement monitoring would be reduced and services would be more effective.
§ 8.5.0 GLBT
§ 8.5.1 Life partners ought to be covered by all insurances and laws, under the same terms as spouses, and must be recognized by practitioners for living wills, advanced directives, survivorship, estate planning and executorship. It’s criminal for providers to give precedent to the wishes of a sibling not seen for 20 years when one’s life partner stands by unrecognized while their partner lays dying. The interstate commerce clause also ought to assure recognition of marriage from one state to another and it ought to super-cede the “Defense of Marriage” Act.
§ 8.5.2 Youth and adults who are facing identity crises ought to be provided counseling paid for by all insurance plans.
§ 8.5.3 In my opinion, GLB is otherwise not a health issue. Transgender issues are certainly health issues.
§ 8.5.4 In my opinion, GLBT ought not be a factor for security clearances or military service, providing that one’s external behavior is lawful and consistent with one’s internal psyche. The problem emerges when one’s internal state (say bisexual) is kept hidden from co-workers, spouse, other partners, parents, or children. It is then that one can be blackmailed by foreign intelligence or terrorist or gang groups. Otherwise, it ought to not be an issue and “don’t ask, don’t tell” ought to be modified to, “If I am fearful and have to keep it a secret, then I could be blackmailed and become a threat to national security.”
§ 8.6.0 MILITARY
§ 8.6.1 There are 9 M covered under the military’s Tricare program. The total cost of Tricare was $39 B in 2007. That averages only $4,333 per person, about $4,000 less than the average cost of health care PP. Some ex-military obtain services through the VA. Some military are eligible for Medicare. Some military obtain retiree health insurance through private employers after military service.
§ 8.6.2 The Military Officer’s Association reports that DOD spending on healthcare is comparable to health care spending by corporations. Few people, especially in Congress, would vote to increase the costs of health care to current or former military. Most people would strongly advocate comprehensive health care for disabled military and probably competitive health care for other military personnel. Promises made to our veterans in which we obligated ourselves to provide quality care must be honored. I calculate that our nation needs to be spending an additional $9 B a year to meet these obligations. I recommend designating $2.5 B a year for coverage of basic services through the FHCs and increasing coverage $6.5 B a year for “Tricare” programs for retired military personnel.
§ 8.6.3 Over the past 60 years, the US has used military personnel and some civilians for medical experimentation. Some of the experimentation has resulted in chronic conditions. A program to study long term effects of medical experimentation across all federal agencies must be conducted. I propose that ongoing studies will cost $500 M a year more. The results of studies must be transparent and posted on the internet.
§ 8.7.0 VETERAN’S BENEFITS
§ 8.7.1 We must provide expanded coverage for disabled veterans, other veterans, and dependants.
§ 8.7.2 We ought to provide housing in a structured setting for 250,000 homeless veterans, providing therapeutic and vocational services. Many veterans experience PTSD and have difficulty re-integrating into society. This program would help the re-integration process. I propose that the operations for this program would be paid for through the VAMC and would cost $10 B a year. This would require infrastructure investment for housing. Some housing programs might utilize rehabilitated closed military bases. Overall, housing infrastructure investments would cost $5 B for each of the next 4 years. We have a national infrastructure to re-construct (e.g., roads, highways, E-rails, bridges, schools, energy systems, enhanced agricultural centers). Many of these soldiers might contribute through a sub-program of Ameri-Corps. This would cost $8 B a year. Savings of re-adjustment health care, PTSD services, societal costs, would be $5 B a year.
§ 8.7.3 A re-introduction of the 1950s GI Bill could provide education in needed fields and reduce effects of PTSD currently suffered by 400,000 troops. I see that Senator Webb’s bill was recently passed. One problem is that the cost of housing varies from Appalachia to New York City and some housing modification might be appropriate. The tuition benefit is tied to tuition at that state’s universities. Given that some states, like California, provide comprehensive tuition assistance whereas other states offer less competitive assistance, this tuition benefit varies greatly by state, with people who want to attend a private school in California having to pay 95% of the tuition. I suggest a flat national tuition reimbursement, perhaps modified by cost of living adjustments as reflected in the federal pay schedule. I estimate that this supplement to Senator Webb’s previous bill would cost $2 B a year for each of the next 10 years.
§ 8.8.0 HALFWAY HOUSES (HH)
§ 8.8.1 HHs require greater, consistent oversight.
§ 8.8.2 “Predators” (rapists) and “prey” (retarded women alcoholics) should not reside together.
§ 8.8.4 The range in quality demands basic centralized standards not yet offered.
§ 8.8.5 Staff ought to have a nationally recognized, basic certification.
§ 8.8.6 HH’s might be arranged by needs (e.g., Parkinson’s) or interests (e.g., young adult).
§ 8.9.0 INDIAN HEALTH SERVICE
§ 8.9.1 It is estimated that 1.4 million Native Americans (NAs) / Alaskan – Americans / Pacific Americans obtain health care services through IHS and another 500,000 are eligible. The IHS budget in 2008 was $3.58 B. IHS also obtains $650 M a year from CMS, resulting in total expenditures of $4.23 B a year ($3,021 per person).
§ 8.9.2 As health care costs the average American $8,333, the federal spending of $3,021 per NA is noteworthy. Why the difference?
· Might NAs use more non-traditional medicines? – No.
· Might non-traditional medicines / procedures be more efficacious than traditional methods? – No.
· Might NAs trust traditional medicine less? - Yes.
· Might NAs be less trusting of the US government and employees? – Yes.
· Might NA health care be a lower priority for the US government? – Yes.
§ 8.9.3 NAs have a lifespan 4 years shorter than the average American. NAs have higher rates of obesity, MI; death caused by tuberculosis (750%), alcoholism (550%), auto accidents (335%), diabetes (190%), unintentional injuries (150%), homicide (100%), and suicide (70%).
§8.9.4 Elsewhere, I reduce US health expenses $833 B, with total health expenditures of $1,667 B / yr ($5,555 per capita). Justice demands equal treatment for NAs and an increase in the IHS budget of $3 B a year to rise to the average of $5,555. If we don’t reduce health care costs, the $8,333 per capita would translate to an additional $7.44 B a year. Reduced costs of living might offset higher disease rates, although I suspect not.
§ 8.9.5 I suggest that the education of NAs be paid for through federal loans and supplemental grants. I would especially encourage them to enter the fields of science, health services, alcoholism counseling, and engineering.
§ 8.10.0 SEX OFFENDERS (SOs)
§ 8.10.1 Sex offenders are broken out because of some of the special problems that they pose, especially general safety. § 8.10.2 Who is a sex offender? That’s a difficult question to answer! A rapist is clearly a sex offender. Is the rapist who keeps clothes on himself and the other person and is apologetic equally as dangerous as the rapist who keeps an unclothed slave in a torture chamber? Is an 18 year old boyfriend of a 17 year old girl a child molester even if they’d been dating for 3 years? Are female teachers who gain the trust of their male victims and manipulate and seduce them more dangerous than a stranger? Should someone who uses a weapon be considered more dangerous than someone who does not? And, many states use a system in which SOs are not identified until they have been convicted of three dangerous offenses. So, the 18 year old boy who was convicted of having a relationship with the 17 year old girl 3 times could be seen as equally dangerous as the 50 year old man who raped and tortured 10 girls. A crippled veteran who finds it difficult to attract girlfriends might seek sexual relations with a prostitute. He might be a sex offender. A 12 year old boy having relations with an 11 year old girl might be a sex offender. Is a man who peeks in windows or rubs up against you in the elevator or who gazes at pornography a sex offender? What about the husband of 20 years who always respected his wife’s decisions but he gets intoxicated that night and forces himself on her – is he a sex offender?
§ 8.10.3 TREATMENT: Should SOs receive medical treatment for general conditions? In my opinion, of course they should.
§ 8.10.4 TREATMENT: Should SOs receive medical treatment for sexual offending? Is this treatment designed to reduce or eliminate the offenses? How efficacious is it? How costly is it? How costly is a re-occurrence and what is its probability? How costly is long-term care? What are the side-effects of medical procedures? Ought medical procedures that are not empirically based be permitted? If not, how can such procedures become empirically based unless we experiment in order to determine efficacious treatments.
§ 8.10.5 RESIDENCIES: SOs are often housed in state facilities after a prison sentence is finished, as the state considers them a continuing danger to society. They receive a lifetime of free room and board and treatment. Work, in which services or products can be safely provided or manufactured within the facility, must be provided by these SOs. Their work would result in profits that would be used to pay their restitution to victims, court costs, treatment, and personal (e.g., child support and personal funds).
§ 8.10.6 One GAO study which relied on “incomplete” state reporting, identified that 700 of 1.5 M people in long term care facilities were registered SOs. The definition of an SO varies tremendously by state law. In Virginia, it is someone who has been convicted of 3 violent sexual offenses. Thus, people who rape only once or twice are not considered SOs, often. This limitation really skewed the data, as the GAO was only looking at the worst of the worst. Just over half of the information was reported to the GAO, so, the calculation of 700 SOs might actually be 1,400. States might be highly cognizant and closely monitor and report on SOs in LTC facilities OR states might try to hide the fact that they are housing SOs in these facilities. Bottom line: be cautious when you place your mom in a NH, as SOs are sometimes placed there. Given the “turn over” rate of the populations in NHs, the probability that someone with a history of a sexual offense will reside in any one facility at any time over a 3 year period is very high. It doesn’t mean that they will re-offend, but, they might.
§ 8.10.7 I wonder, since we have already established special state facilities for post-prison SOs that has been reviewed by the USSC, perhaps special NHs and HHs could be developed for persons with histories of sexual offenses. These facilities would not be criminal justice facilities. They would be health care facilities. But, they might have special thought built into them – not located near a school, locks and gates, shielded nursing stations, open spaces. Behavioral specialists and medical personnel trained in working with patients with SO histories ought to be available. Housing SOs away from vulnerable victims makes sense.
§ 8.11.0 ADOPTION, ABORTION, AND GENETIC COUNSELING
§ 8.11.1 Ought school district nurse’s offices and Federal Health Clinics offer free condoms to youth? US teen pregnancy and abortion are decreasing, but still, 750,000 teens get pregnant and about 250,000 of them end in abortion!
§ 8.11.2 Raising 500,000 babies born to teen mothers costs nearly $100 B a year. With that money, we could pay most public higher education tuition; we could provide every American with 800 condoms; or, we could buy 20 Nimitz class aircraft carriers every year!
§ 8.11.3 I don’t want to step into the debate of the rightfulness or wrongfulness of preventing pregnancy. I would say that providing condoms at schools and FHCs might postpone pregnancies slightly, until teen girls are more mature and the couple can provide better support for a child.
§ 8.11.4 Hundreds of thousands of [adult] couples would give anything for a healthy baby.
§ 8.11.5 All reasonable expenses associated with Americans adopting American children ought to be covered with advances in tax rebates, so that working-class couples could immediately meet adoption costs.
§ 8.11.6 For more financially needy families, the government might provide continuing health insurance for adopted children until 18 or completion of college.
§ 8.11.7 International adoption costs might be tax deductible when consistent with national immigration policies.
§ 8.11.8 Placement of racial minorities, older, and unhealthy children could be increased through active recruitment, education / training that is needed to improve the skills and confidence of prospective parents, and financial incentives.
§ 8.11.9 Abortion of neonates whose mothers’ life is threatened could, from a macroeconomic view, reduce costs associated with health care and mortality. Females whose lives are threatened by pregnancy, who comprehend options, and who decide to have an abortion ought to be able to obtain that abortion. Expenses ought to be covered by public insurance, tax rebate, or deduction.
§ 8.11.10 - I shall not address the issue of abortion for mothers who have been raped or for mothers who simply wish to have an abortion.
§ 8.11.11 - Pregnancy prevention information ought to be required of all females who obtain abortion services. A brief offering for spiritual counseling might be covered.
§ 8.11.12 - What about when a 29 year old TN man has fathered 21 children to 11 women and all children are on state programs? What right might the state have in assuring that the man does not produce a 22nd child when it’s already going to pay $8 M to raise these children through age 18? 22 children on state programs might cry for a right for state intervention. But, what about more ambiguous levels such as 10 or 5 children?
§ 8.11.12 - Could the state require abortion for neonates of heightened genetic vulnerability, say a child with a 90% probability of severe disease? Couldn’t the state require abortion for neonates not Arian or not male?
§ 8.11.13 - The US’ 1920s program of forced sterilization makes this naïve historian wonder to what extent US customs might have paved the way for Nazi German abuses 15 years later?
§ 8.11.14 - The cost of lifetime support programs for the developmentally delayed exceeds $45 B a year or $10 M over a lifetime. Could we provide greater financial support for these programs, better resources, more and better paid staff, but then also reduce the population of residents through abortion of the least sustainable 10%? Again, this introduces a slippery slope to which I am not comfortable addressing.
§ 8.11.15 - Genetic testing for couples with greater risk for disorders ought to be required and follow-up genetic counseling ought to be available. Findings for genetically-carried disorders, such as Huntington’s Disease (HD), might allow the couple to make better, healthful, informed decisions.
CHAPTER 9:
PRISON HEALTH CARE & RELATED REFORMS
“Hunger makes a thief of any man.” - Pearl S. Buck
“I'm convinced that every boy, in his heart, would rather steal second base than an automobile.” - Tom Clark
“In hospitals there is no time off for good behavior.” - Josephine Tey
§ 9.1.0
§ 9.1.1 Prison health services are sub-par and DOJ ought to prosecute cases where prisoners are denied care. Denial of health care is cruel and unusual punishment, if not murder.
§ 9.1.2 Where no ROI is projected, many “elective” procedures are less utilitarian.
§ 9.1.3 Low offered salaries mean unfilled positions and savings to the prison and government. When done with intent, it seems to me to be a crime, denying prisoners health care. The average salary of prison providers ought to be set in order to attract more applicants, even if below average, it ought to be sufficiently attractive. Much care might be provided by less costly PAs, NPs, LPNs, hygienists, and master’s level counselors.
§ 9.1.4 Prison health services might be contracted with FHCs.
§ 9.1.5 75% of prisoners have Substance Abuse (SA) disorders and 50% of prisoners have a MI. Back in the 1950s, most people with MI were treated in hospitals. Now, they are warehoused in prison, one-third the cost of the costly inpatient psychiatric hospitals. Prison-based treatment programs are needed and just.
§ 9.1.6 Prisoners who can, should work. The US infrastructure requires significant investments. If they earn half what high school graduates earn, that’s $16,500 x 2 million prisoners = $33 B a year. Medicare and SSA contributions total $6 B a year. The $30 B might be divided equally ($6 B each) between prisoners (and child support), victim compensation, fines and court costs, prison operations, and prison health care improvements. They’d also be contributing $6 B a year toward taxes, FICA, and Medicare.
§ 9.1.7 Vocational programs would cost $4 B but lead to more career options, further increasing revenues.
§ 9.1.8 While many prisoners don’t want to change, some do. For them, instead of spending $40,000 for each of ten years in prison, providing housing, literacy programs, GED, college, and health sciences education, those “investments” could be “re-paid”. When one falls into the justice system, it is generally either because of antisocial personality or society has failed the person.
§ 9.1.9 Release and transition programs must be coordinated with the community. Relocation to another community and removal of gang tattoos might be needed. Supervised housing, social support, health care, immediate employment with modest wages ought to be provided, even if through expanded Ameri-Corps programs. Close supervision by addictions specialists, vocational counselors, and parole officers must be provided.
§ 9.1.10 The immediate return of 250,000 IAs to their home nations will reduce prison expenses. Release (with above prevention / treatment / transition programs) of an additional 200,000 (least risky nearing parole = 8%) will reduce prison expenses.
§ 9.1.11 Several thousand contract AIDS while in prison every year, partly due to unsafe sex practices and lax security procedures. Prison health clinics often don’t provide condoms. Modification of security practices, availability of condoms, and prevention programs will reduce AIDs, saving tens of millions of dollars and thousands of lives each year. Early detection services could reduce the chance that HIV will lead to AIDS. No one deserves harsh conditions or contracting of AIDS in prison.
CHAPTER 10
“ILLEGAL ALIENS” (IA) PROGRAM
“Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tossed to me, I lift my lamp beside the golden door!" – Inscription from the Statue of Liberty
§ 10.1.0 Program for IAs
10-15 million IAs are uninsured – it costs an estimated $50 billion a year to provide health care for IAs. Dealing with issues of IAs is integral to effective, efficient, and just health care reform as well as the larger issue of what to do about 5% of the American people being here illegally. I recommend the following -
§ 10.1.1 Rotate national guard units along the US southern border. Increase FL, TX, and CA coast guard patrols. Troops ought to carry taser guns, weapons with rubber bullets, and tear gas, to balance enforcement needs with respect and reduced injuries.
§ 10.1.2 Troops ought to have immediate access to more lethal weapons in order to match deadly assaults.
§ 10.1.3 Satellite imaging and drones will increase efficiency, track aircraft, and locate tunnels.
§ 10.1.4 As tunnels are prevalent, a wall at least 20 feet deep and 40 feet tall (as in Israel) is required. A fence won’t work.
§ 10.1.5 Emergency medical care must be provided. The fence construction will save several hundred lives each year in comparison to the dozens of deaths from patrols (mostly related to drug smuggling).
§ 10.1.6 IAs with a felony or violent offense conviction must be returned immediately to country of origin. That ought to include the 250,000 IAs currently housed in overcrowded US prisons. Some jurisdictions might fight to keep some IAs and in such cases those IAs might be retained.
§ 10.1.7 If one wishes to return to the US, a standard application ought to be submitted.
§ 10.1.8 All IAs must register with INS, through post offices or SSA offices. Think about this: many IAs work on farms harvesting crops and earning a couple hundred dollars a week, or less, significantly less than minimum wage. The large agricultural corporations that benefit from cheap labor couldn’t compete if it had to attract American laborers. We’d be buying wheat from China! IAs have been holding the jobs the rest of us don’t want. They are like every other immigrant group that came to the US before them. Given the proximity, we have a higher proportion of them being here illegally than before, and this must be addressed realistically and justly. Domestic producers of foods that rely on IA labor will need transitional assistance and perhaps tariffs on imported goods so that they can pay minimum wage, payroll taxes, and health insurance.
§ 10.1.9 Every registered, non-violent, non-felon IAs will be provided a five year period to (im) prove oneself. All IAs ought to be encouraged to take classes to develop English literacy, complete naturalization courses, acquire the GED, and complete other education (especially nursing). IAs would be eligible for student loans and incentives for study, especially in areas critical to national interests. What do you think about IA eligibility for PELL grants?
§ 10.1.10 - Health care of registered IAs would be provided by the government, employers, colleges and, for a first time, working IAs.
§ 10.1.11 - Employment of registered IAs would be lawful and employers would not face fines or charges, although salaries must be competitive with salaries of non-IAs or else the employer would face criminal charges. As always, the minimum wage and OSHA standards would apply. FICA and Medicare would be required contributions or taxes and, if they choose to not remain in the US, would forfeit any such contributions. Employers would be responsible for payroll taxes for registered IAs. Registered IAs would be eligible to participate in an expanded Ameri-Corps Service Program. Employment of unregistered IAs would be a criminal offense as well as subject the employer to federal charges of tax evasion and harboring a fugitive.
§ 10.1.12 - With “registered” status, IAs could hold TAXABLE jobs.
§ 10.1.13 - Those who do not demonstrate improvement, contribution, and pass naturalization courses within 5 years ought to be made to return to their home nation. Annual INS progress reports should be required.
§ 10.1.14 - By accepting driven IAs and expelling the violence-prone, the US would increase tax revenues and reduce the retiree to worker ratio. By making this simple move, we would help Medicare and SSA survive 5 to 10 more years.
§ 10.1.15 – As for costs, the primary cost would be educational loans and assistance for domestic farming.
§ 10.1.16 - Individuals who end up working in designated areas – health care, public schools, civil engineering – might obtain tax rebates.
§ 10.1.17 - Increased GDP during each year in first 5 years will be $330 B, increasing to over $500 B / year after the first 5 years.
NEW ANNUAL TAX REVENUES FROM LEGALIZATION OF ILLEGAL ALIEN WORK PROGRAMS
NEW TAX RATE @ $330 B @ $500 B
Medicare Taxes 2.90% $9.6 B $14.50 B
Social Security 12.20% $41.0 B $62.00 B
Federal, State, Local & Property 14.00% $46.2 B $70.00 B
“Fourscore and seven years ago our fathers brought forth on this continent, a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal.” - Abraham Lincoln
CHAPTER 11
SOME NOTEWORTHY MEDICAL CONDITIONS
“He who has a why to live can bear almost any how.” - Friedrich Nietzsche
“The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.” - Plato
§ 11.1.0 OVERVIEW OF SOME MEDICAL CONDITIONS
§ 11.1.1 As I wrote this section, I had an epiphany. Every one of us alive today will die from one thing or another. If we’re successful, every one will die of really old age. We seem to be passing off death from one disorder to another as we pass through each age.
§ 11.1.2 THE 10 MOST COSTLY DISEASES TO TREAT IN THE UNITED STATES
Heart Conditions $76 billion Trauma Disorders $72 billion
Cancer $70 billion Mental Disorders $56 billion
Asthma & Pulmonary Disease $54 billion High Blood Pressure $42 billion
Type 2 Diabetes $34 billion Osteoarthritis and Other Joint Diseases $34 billion
Back Problems $32 billion Normal Childbirth $32 billion
§ 11.1.3 THE MOST COMMON CAUSES OF DEATH IN THE UNITED STATES IN 2006
Heart Disease: 631,636 Cancer: 559,888
Stroke (cerebrovascular diseases): 137,119 Chronic Lower Respiratory Diseases: 124,583
Accidents (unintentional injuries): 121,599 Diabetes: 72,449
Alzheimer's Disease: 72,432 Influenza and Pneumonia: 56,326
Nephritis, Nephrotic Syndrome, & Nephrosis: 45,344 Septicemia: 34,234
Suicide: 33,300 Liver Disease: 27,555
Hypertension: 23,855 Parkinson’s Disease: 19,566
Assault (Homicide): 18,573
About two-thirds of the above deaths are attributed to our BEHAVIORS and could be prevented, delayed, or altered by our changing our behaviors. Behaviors such as overeating, lack of exercise, smoking, drinking, poor stress management, DUI, not obtaining annual physical examinations and preventive care, not obtaining help for assaultive tendencies / staying with violent partners, bottling up our feelings, anxiety, depression, and illicit drug use contribute to our own illnesses, QOL, and deaths.
§ 11.2.0 MENTAL ILLNESS & SUBSTANCE ABUSE
“One may have a blazing hearth in one's soul, and yet no one ever comes to sit by it.” - Vincent Van Gogh
PREVALENCE AND COST
§ 11.2.1 From 2000 to 2004, MI diagnoses increased 41% (23.9 M to 33.8 M). Why outpace population growth 41% to 5%? More diagnosticians? More sickly? More psychotropics? Better drug marketing? Need by patients to re-present for treatment because initial presentations were denied? During those 5 years, there was a dramatic increase in the number of diagnosticians, number of psychotropic medications being marketed, and more stress on the US population, with terrorism, war, declining economy, increased bankruptcy filings, and, if you believe physical health diagnostic data, increased illness.
§ 11.2.2 Costs of treating the MI increased from $37 B ($1,575 a person) in 2000 to $52 B ($1,538 a person) in 2004, an increase of $15 B in the aggregate but a PP decrease of $37. The over-supply of MI therapists in consort with strict managed care reduced these costs in the short term. As MI treatment is related to reduced abuse of other medical services, one might expect that during this time period, more patients presented to physicians with more physical complaints.
§ 11.2.3 Tremendous increases in diagnosis and outpaced spending was found in all fields (except trauma – which is solely in the hands of patients and which increased only 5% and MI which DECREASED costs PP by $37).
“Love cures people - both the ones who give it and the ones who receive it.” - Dr. Karl Menninger
§ 11.2.4 From 2000 to 2004 –
15% n Payments to MI Providers 14% o # of MI Providers
41% o # with MI – 24 M to 34 M 38% o Total Costs - $37B to $52 B
25% o Psychotropic Drug Costs 29% n Payments for Ave Provider
8%o General Inflation
§ 11.2.5.1 - DISPROPORTIONATE USE – THE FACTS:
25% of the “top 5%” of health care users had a serious MI
3% of the “bottom 50%” of health care users had a serious MI
§ 11.2.5.2 – DISPROPORTIONATE USE – HYPOTHESES:
Serious MI Patients Might Be Genetically More Susceptible to Physical Diseases
Serious MI Patients Might Need Genuine Positive Regard That Is Received from Doctors & Nurses
Serious MI Patients Might Not Receive Needed MI Treatment So They Obtain Needs Elsewhere
Serious MIs of People with Serious Medical Conditions Are More Likely to be Observed & Diagnosed
People with Serious Medical Conditions Are More Likely to Get Anxious or Saddened
§ 11.2.6 I calculate US MI costs, contributions to onset of other medical conditions and non-compliance, and employment / school inefficiencies at $600 B, plus 137,000 deaths annually directly and another 1 M deaths annually are brought on by MI/SA and behavioral choices. More die from MI/SA every month than who died from 9 -11.
TREATMENT:
“Drunkenness is temporary suicide.” - Bertrand Russell
§ 11.2.7 Severe MI must be treated. When it is not treated, the most severe patients with MI seek more medical attention, they seek social welfare programs, they are warehoused in prisons. We pay one way or another for their care. Community MI / SA investments must be increased. Supervised housing, partial hospitalization, day programs, medications; psychotherapy, psychiatric consultations, social work, occupational and vocational therapy lead to: (1) serving those in greatest need, (2) reduced costs, (3) reduced societal costs, and (4) better patient outcomes.
§ 11.2.8 None of us like the thought of paying for the “worried well”. By designating procedures “medically necessary”, “medically recommended”, or “elective”, individuals with the least severe need for services might not receive tax incentives.
§ 11.2.9 75% of psychotropics are prescribed by PCPs who must complete psychiatric CEPs.
§ 11.2.10 - Given the benefits of lower medical and societal costs and enhanced productivity, annual MI check-ups ought to be encouraged and covered.
§ 11.2.11 - Congress must mandate state services specifically and provide more uniform coverage (WV Medicad pays 33% more than VA).
§ 11.2.12 – Long-term Cost / Benefit Analysis Must Be Conducted:
YEAR 1: MEDICAL ONLY YEAR 1: MEDICAL AND PSYCHOTHERAPY
Doctor Visits 6 x $125 = $750 Therapist Visits 25 x $80 = $2,000
Imaging 1 x $2,000 = $2,000 Doctor Visits 2 x $125 = $250
Lab Work 4 x $100 = $400 Lab Work
Medications 12 x $200 = $2,400 Medications 6 x $150 = $750
$5,550 $3,000
YEAR 10: MEDICAL ONLY YEAR 10: MEDICAL AND PSYCHOTHERAPY
Doctor Visits 2 x $125 = $250 Therapist Visits 2 x $80 = $160
Medications 12 x $250 = $3,000 Doctor Visits 2 x $125 = $250
$3,250 $410
MEDICAL ONLY COSTS: $34,800 MEDICAL AND PSYCHOTHERAPY COSTS: $6,690
The average patient who remains on an antidepressant for 10 years gains 20 pounds. This weight gain can
result in related medical costs (Diabetes, hypertension, cancer, heart disease …) that far exceed the cost of treating the original depression. In most cases of MI, I advocate psychotherapy, with more physiological symptoms, the more often I suspect medicine is merited as an adjunct to psychotherapy. Most psychotropic medications ought to be limited in use to the initial first 6 months while a person learns new coping techniques in psychotherapy – at least for 90% of people. The other 10% MUST stay on their medication long term or risk serious consequences.
§ 11.2.13 - OP MI payments must increase, especially in underserved communities to at least cover costs.
§ 11.2.14 - Public hospitals must offer a slight increase in the number of beds and must be paid more. Those hospitals also have too much ADMIN overhead. Geriatric units are increasingly important as dementia prevalence increases. Alternatives to psychiatric hospitalization, such as partial hospitalization programs, NHs, ALFs, HHs, can save hundreds of millions of dollars a year.
“Every form of addiction is bad, no matter whether the narcotic be alcohol or morphine or idealism.”
- Carl Gustav Jung
§ 11.3.0 ARTHRITIS
· Arthritis affects 14% over 25 and 33% over 65
· 2008 costs = $81 B (direct) and $47 B (indirect)
§ 11.4.0 PULMONARY DISEASE
“For breath is life, and if you breathe well you will live long on earth.” - Sanskrit Proverb
§ 11.4.1 Pulmonary disease was the 4th most costly disease to treat in 2000 and the 5th most costly to treat in 2004.
§ 11.4.2 From 2000 to 2004, the diagnosis of Pulmonary Disease increased from 43.2 M to 46.7 M (8%).
§ 11.4.3 Costs increased from $39.8 billion ($922 per person) in 2000 to $48.7 billion ($1,042 per person) in 2004. Total costs increased 22%. Costs per person increased 13%. Inflation during this time was 8%.
§ 11.5.0 MULTIPLE SCLEROSIS
§ 11.5.1 Multiple Sclerosis (MS) prevalence ranges from 250,000 - 600,000 in the US. Prevalence in women is 3 times that of men. Caucasians are more likely to develop MS than minorities, although the geography distribution makes racial vulnerability conclusions questionable. Total costs are ~ $23 B a year.
$ Mild MS = $32,297 / year $ Moderate MS = $50,293 / year $ Severe MS = $65,173 / year
§ 11.6.0 CANCER
“Cancer is a word, not a sentence.” - John Diamond
§ 11.6.1 Among non-institutionalized US civilians, cancer was the third most costly disease to treat in 2000 and the second most costly disease to treat in 2004.
§ 11.6.2 Cancer diagnoses increased 17%, from 9.3 M in ‘00 to 10.9 M in ‘04.
§ 11.6.3 The cancer diagnosis rate was 3 times the rate of population increase. Are we unhealthier, are diagnosticians better, or are there simply more diagnosticians who over-diagnose?
§ 11.6.4 Expenses increased from $42.4 B ($4,577 a person) in 2000 to $62.2 B ($5,727 a person) in 2004. Total costs increased 47%. Per capita costs increased 25% while inflation increased 8%.
§ 11.7.0 END STAGE RENAL DISEASE
Prevalence = 506,000 Mortality = 16.4% ESDR Program Cost = $33.6 B
§ 11.8.0 TRAUMA
“I'm not saying there won't be an Accident now, mind you. They're funny things, Accidents. You never have them till you're having them.” - Eeyore in Winnie the Pooh
§ 11.8.1 Among non-institutionalized US civilians, trauma was the second most costly condition to treat in ‘00 and the third most costly in ‘04.
§ 11.8.2 From 2000-2004, trauma increased from 34.2 M to 35.8 M (5%) - same as US population increase.
§ 11.8.3 Expenses increased from $45.8 B ($1,340 a person) in 2000 to $58.5 B ($1,635 a person) in 2004. Expenses increased 28% (22% a person) while inflation was 8%.
§ 11.9.0 PAIN MANAGEMENT
“Sweet is true love that is given in vain,and sweet is death that takes away pain.” - Lord Alfred Tennyson
§ 11.9.1 A high proportion of pain patients are drug seeking and engage in doctor shopping. Others are often in severe pain and require aggressive measures. Physicians are not trained adequately to the point that law enforcement ought to always charge a physician for criminal conduct related to prescriptions. Some physicians, on the other hand, do cater to a clientele that is drug seeking and much money is made from that service. EMRs would help identify physician signatures or patterns that differentiate fraud from caring for those in pain.
§ 11.9.2 Medicine to relieve founded pain is essential.
§ 11.9.3 Many pain medicines lead to increased tolerance to the drug, so, more and more of that drug is required.
§ 11.9.4 Doctors must closely supervise changes in drugs and doses.
§ 11.9.5 When patients have terminal illness, doctors ought to have greater prescription authority.
§ 11.9.6 The combination of increased SA treatment, use and monitoring of EMRs, and keener analysis by law enforcement ought to reduce drug seeking.
§ 11.9.7 I advocate establishing pain centers, affiliated with VAMCs, FHCs, cancer centers, hospice programs, and even law enforcement agencies. The approach must be inter-disciplinary.
§ 11.9.8 The ability to prescribe the most potentially lethal medications might be restricted to physicians w have completed specified Continuing Education Programs on Pain Management.
§ 11.10.0 DIABETES
PREVALENCE AND COST:
§ 11.10.1 - Diabetes prevalence is ~ 24 M, plus it is estimated that another 6 M are undiagnosed. Prevalence is related strongly to age and race, although these might be confounds for other factors such as weight, eating habits, and exercise level.
§ 11.10.2 - 130 M Americans are overweight or obese.
§ 11.10.3 - Diabetes leads to blindness, stroke and heart disease, kidney disease, and neuropathy.
§ 11.10.4 - Diabetes costs about $150 B per year.
TREATMENT & MANAGEMENT:
§ 11.10.5 - Non-compliance with medical regimens is costly. Support groups, prevention and compliance counseling,and randomly generated telephone calls from the provider’s office asking about compliance and offering to answer any questions can increase compliance.
§ 11.10.6 - Many people with “pre-diabetes” who lose weight and exercise can reduce diabetes development.
§ 11.10.7 - SA - like treatments ought to be available for diabetics who become “addicted” to extreme highs and lows associated with blood – sugar changes.
§ 11.10.8 - Weight reduction, compliance improvement, and GBS ought to be covered by all policies.
§ 11.11.0 HEART DISEASE
PREVALENCE AND COSTS:
§ 11.11.1 - For non-institutionalized US civilians, heart disease was the most costly disease in 2000 and 2004.
§ 11.11.2 - From 2000 to 2004, heart disease increased from 17.3 M to 20 M (16%), 3 times the population increase. Are Americans living lifestyles that makes us more vulnerable to heart disease? Are there better diagnostic tests? Are there more cardiologists needing business?
§ 11.11.3 - Expenditures increased from $61.8 B ($3,581 PP) in 2000 to $90 B ($4,508 PP) in 2004. Total expenditures increased 46% (26% PP) while inflation increased 8%.
§ 11.11.4 - The total societal and medical costs of heart disease and stroke are $448 B per year.
TREATMENT:
§ 11.11.5 - Cardiologists generate over $2.5 M / yr each for just surgeries. Their gross income is 4 times greater than that of the average physician. For several years’ investment of time in a surgical residency paid modestly, it is usually an excellent ROI. I want the doctor with my heart in her hands to be well compensated. Cardiothoracic surgeons on salary earn a median of $437,000 / year, down significantly from a decade earlier when the pioneers in this field commanded astronomical payments.
§ 11.11.6 - Many procedures are not justified by evidence that they improve mortality or morbidity.
§ 11.11.7 - When paying $90 B a year for heart surgeries, in times of national economic hardship, we must ask, “what is the evidence that justifies the single most costly procedures in the field of medicine?”
§ 11.11.8 - The US has several time more cardiac surgeries per capita than other OECD nations. Still HD is the most frequent killer. This is likely due to unhealthy lifestyles. Cardiologists always do only that which is medically necessary and they never do any medical procedure for any reason other than the needs dictated by the patient’s medical condition. Right? It is estimated that half of US bypass surgeries and stint placements are not medically necessary.
§ 11.11.9 - Gatekeepers are less likely to deny a $50,000.00 bypass than a social workers’ request for an $80 MI intake.
§ 11.11.10 - Angioplasties seem more medically beneficial than bypass surgeries. Many reports on $20,000
angioplasties describe surgery and findings in two sentences. Can’t we have a picture or a clear description, or
maybe even STANDARDS for reporting exploratory surgery?
§ 11.11.11 - US deaths from heart disease decreased from 710,000 in 2000 to 629,000 in 2006, suggestive of greater efficacy of prevention, treatments, healthier lifestyles, or different pathology reporting / Cause of Death findings.
§ 11.12.0 THE SLEEPING DRAGON: ALZHEIMER’S DISEASE (AD) AND RELATED DEMENTIAS:
§ 11.12.1 - The baby-boomer generation will increase the total of Medicare recipients in the next 25 years by 77%! Thus,we can anticipate increasing rates of Alzheimer’s Disease.
§ 11.12.2 - AD is the sixth leading cause of death, increasing 47% between 2000 and 2006.
§ 11.12.3 - In US, 5.3 M have AD. Projected prevalence is 7.7 M in 2030 and 11-16 M in 2050.
§ 11.12.4 - Cost is $175 B / yr.
§ 11.12.5 - In US, 10 M, mostly female relatives, are unpaid caregivers for people with AD, donating 8.5 B hours, valued at $94 B. Caregiver burnout is extreme.
§ 11.12.6 - While health care costs averaged $10,600 PP in 2004 for Medicare, AD costs were $33,000 PP.
§ 11.12.7 - 1.8% has AD in 2009, increasing to 2.2% in 2030 and 2.6% in 2050, with US aging. AD costs US PP $583 in 2009, $688 PP in 2030, and $807 PP in 2050, not counting inflation.
§ 11.12.8 - Specialized AD units in NHs are needed and must receive modest public funding increase over standard NH care, as they cost 20% more. Specialized AD units ought to be located so as to serve rural regions in an efficacious manner. They must be large enough to be able to make a full inter-disciplinary team viable so that enough patients can make the fixed costs affordable.
§ 11.12.9 - We must not divert resources from a needful, less utilitarian population. A wise society would fund research so that seniors would be able to contribute to society and not become victims of such diseases.
§ 11.12.10 - I believe that if we fund research on this disease at proper levels, we can identify ways to prevent it and most efficaciously treat it.
§ 11.13.0 INFERTILITY TREATMENT
“Children are poor men's riches.” - English Proverb
§ 11.13.1 - Every one of us can point to some procedure and say, “that’s not necessary”. Infertility treatment is one of these. Given the world population explosion and large numbers of children needing a family, adoption seems like a wiser route than infertility treatment. I must say that infertility treatment, given the circumstances of all the children without families, appears to be a heroic act of ego. That said, reproduction is our most primal desire.
§ 11.13.2 - I suggest that some procedures, such as infertility treatment, might be “elective” procedures and, thus, meriting less insurance coverage and less favored tax status.
§ 11.14.0 ABORTION
§ 11.14.1 - I believe that women must have the right to have an abortion and have control over their bodies. I sure would hate to have a government bureaucrat tell my granddaughter that she had to give birth even if that killed her. In my opinion, that might be too much government interference. If the government holds the right to tell my granddaughter to do something that will kill her, then it has the right to withhold medical treatment that will kill me but authorize treatment for people whom it considers to be desirable. The government would have absolute control over everybody and everything. That can be a frightening thought. That ought to not be allowed.
§ 11.14.2 - However, I personally believe that abortion is fundamentally wrong and if people didn’t have control of their bodies during inception, then they might have less control over their bodies today which might suggest that since their decision-making process was not up to prime at the time of inception, that they might not possess the soundness of mind today to command the performance of an abortion.
§ 11.14.3 - Sometime, probably not in this health care reform bill, we ought to discuss situations in which people may or may not seek an abortion:
Early Term Mid-Term Late-Term
Threat to Mom Threat to Child Too Costly to Society
§ 11.14.4 I’m too conflicted in this matter to offer sound, objective opinions in either direction.
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