Critical Care Medicine - List
http://www.pitt.edu/~crippen/

Managed health care and the art of protest: "You can get anything you want at Alice's Restaurant (excepting Alice)".

If there is a leader of this board and if that leader has the appointed (or self assumed) title of being fearless, then why in heaven's name have we allowed the Hiliarys and the Columbias of this country to pull the wool over the eyes of our government, insurance companies, AARP, Managed care organizations, the public, and even bankers. Why, oh why have so many of us remained as sheep and remained silent. Are we impotent, afraid or both?? Speak up - leader of the fearless ones.

Fearless Leader:

Ahem......never missing a chance to pontificate....your Fearless Leader rises to the podium once again..... But I don't think it will make you feel much better.

A historical perspective:

Your righteous indignation must be tempered somewhat by the fact that physicians as a political group had a heavy hand in creating the environment that led to "managed care". Back when medical care was affordable, people paid for it in real time just like groceries. It could be a big hit but it rarely broke anyone. If you really didn't need a service, you didn't ask for it because it forced you to alter your finances around it. Health insurance was affordable for the common man and adequately indemnified him/her from disasters.

Enter universal health care for the great unwashed in the form of Medicare and Medicaid (for out-of-towners- these are government sponsored indemnification for the elderly and the poor, respectively). Once that happened, personal liability for purchasing health care services vanished and demand escalated like a V-2 rocket, matched exactly by supply from a burgeoning medical-industrial complex. Instead of "professionals" we became "small businessmen", marketing our services to the community instead of hanging out a shingle and waiting for them to seek us out. The more demand we created, the more we prospered. Physicians and patients danced with the devil in the pale moonlight while the debt silently deepened.

Then the bottom of the barrel came into view. Congressional wonks moved to put providers on the front line for blame when inevitable cuts in service came. Patients were encouraged that nothing was wrong....keep on using services (and keep voting for us) but hospitals and providers were cut back in reimbursement by creating "inconvenience blocks"- escalating paperwork, which if not followed to the letter, resulted in non-payment. Computers were set to deny for the smallest infraction of increasingly complex rules. Physicians howled. Hospitals went belly up.

The self fulfilling prophesy:

At this point in time, it could be argued that the handwriting was on the wall for physician related churning of the pot's diminishing contents. Did physicians move to cut back questionable and even unnecessary services (taking personal financial hits in the process)? Of course not. They reacted like constructors of race cars after a change in the rules designed to slow them down for safety. They went to the design boards and figured out how to beat the rules. Every year the Indianapolis Motor Speedway promoters make rules to slow the cars down; every year they go faster.

Reimbursers figured out that the only way to stop physician's from churning the pot for their own gain was to create an environment that generated decreasing return for increasing market penetrance, finally to form a negative return system where increases in hype and glitz generated no yield. Managed Care is simply the logical extension of that environment. We (Collectively) brought this on ourselves by refusing to act in such a manner as to slow the onset of default in an overheated system. Our motivations were not all that altruistic; we moved to save our own pocketbooks as much as protect our patients, and now the pipers sour song wafts in through the open window. So here we are. Like Pogo, we have met the enemy and he is us. What can we do about it.

You seem to be looking for a Divine Eminence to lead the fold out of this mess. Well, historically there is a sociological premise called the "Great Man Theory". It goes something like this: in every generation there arises great social problems. When any one of these social problems breaks through a threshold, there always arises a "Great Man (or Great Woman) to lead the fold out of danger. Moses, FD Roosevelt, Churchill, Ho Chi Minh, Joan of Arc, Dr. Hunter S. Thompson...... I don't know if the medical situation has broken through the threshold yet, or if it ever will, but for such a "Great Person" to arise in the 90s, radically different problems must be surmounted.

If you read The True Believer, by Eric Hoffer (1951) you will learn that unseating social systems where there is an entrenched establishment having a strong political and financial incentive for status quo is a violent and apocalyptic process. The only way it can be done is by those who have nothing to lose from the creation of anarchy. The bastions of powermongering in this country have not been sitting idle over the past several decades. They have been learning how to diffuse threats to the dominion's technocracy. One of the main things they learned is: If EVERYONE is part of the system, potential dissenters have more to lose than gain by disturbing the status quo.

It wasn't always that way. A bunch of scruffy kids got together and brought down two presidents, radically changing the course of a political establishment. Part of the reason they were able to do so is because they had no investiture in the fruits of powermongering. Conspiring to destroy institutions proceeded because they had nothing to lose and more to gain by creating new institutions. But now everyone, especially everyone in medicine, is a government employee in some fashion. Disturbing the status quo DIRECTLY affects any potential dissenter and makes it much easier to identify and sterilize him/her.

Much like the Internal Revenue Service and the (former) Selective Service, managed Care has evolved into a system designed to be bulletproof from external threats it's designers knew would be in constant attack. The only way to undermine what we perceive as "managed care" is to create an environment where the existing system beats itself to death. As a practical matter, that means the only way to beat it is by mass noncompliance. As Malcolm Fisher once remarked: "If four people march into a recruiter's office and sing a bar of Alice's Restaurant and walk out...it's a movement.....If fifty people walk in........by God, it's a revolution....."

Could we really do it? Lets argue for a minute that this would be feasible; that a mass movement of physicians could snarl up the system and bring it to its knees. First of all, It would require a "Great Man/Woman" to stir the general populace to a Teamster-like frenzy. They are too fragmented to come together by themselves. If MOST physicians could be coerced into, metaphorically speaking, marching into a Medicare/Medicaid office, singing a bar of Alice's Restaurant and walking out, it would bring managed care to a screeching halt in minutes.

Several other unpleasant things would occur simultaneously.

1. Government edicts are non-negotiable. Willful noncompliance is illegal. Ringleaders (The Great Man/Woman) would be quickly identified and jailed.

2. The government would immediately move to bring legal sanctions against all participants, bringing at least 50% of their livelihood to a grinding halt as well, plus legal sanctions. Mortgage payments, Jeep Grand Cherokee payments, private school fees, Master Care/Visa card payments, all would come mercilessly due and languish, creating a serious ripple in the general economy.

3. The government would immediately tell patients that the reason their services have been interrupted is because of those greedy physicians who are putting them at risk by acting in a selfish and antisocial manner. What happened to their Oath? Where is their dedication? They have become Teamsters........."we only work if we have our foot on the neck of management".

The movement would buckle quickly when the pain began, and then the retribution would begin. To the winner go the spoils......

OK, lets argue further that physicians could be whipped up into such a frenzy that Jimmy Hoffa's millions of molecules buried somewhere in a bridge abutment in New Jersey all quivered in syncopation. We pulled it off. We endured the pain and simply outlasted them and the public outcry became unbearable. Little old ladies with blue hair emoliated themselves daily in front of the White House. The Prez wore a flak jacket to breakfast. We beat them and the wonks had to negotiate to save their skins. We would then get to negotiate a NEW DEAL.

Unfortunately, doesn't get us out of the woods. One of the fundamental premises of Hoffer's work is that the same people who bring down the system never enjoy any of the fruits of reconstruction. (Castro and Lenin rare exceptions) They are sacrificial lambs and are forgotten when the new wave of negotiators arrive. Read The Seven Pillars of Wisdom to find out what happened to T.E. Lawrence after the truce in the Desert. So the big question then becomes: which one of us is willing to give a shot at becoming the sacrificial lamb for the New Order.

Not me. I am too old and soft. There was a time when I would have cheerfully gone to the wall and wailed with the best of them. I now have kids that need fed, clothed, educated. I have a Ferrari that needs a low-restriction stainless steel exhaust system. I have a wife who would never let me live it down. If I were to foment such a rebellion, I would create a painful intolerable environment for me and my family, something I am not willing to do. I am at the mercy of a system that knows it has me by the short hairs. I can crow loudly and posture mightily, but in the end I cannot change anything meaningfully because I am a part of it.

So who among us is willing to walk into a Medicare/Medicaid office, sing a bar of Alice's Restaurant and walk out?

"Not me....not me.....Julia.....take Julia".

The Crippen editorial was a bit like listening to Leonard Cohen but made me feel that slashing my wrists wouldn't hurt enough. Is there really no hope. The history of the dilemma is nicely traced.

Medical greed...Cost pressures...Generic managers......"Innovative payment systems"...Loss of medical power.

I don't favour your solutions. There are alternative approaches. History has a habit of taking care of false systems. Natural selection applies to business as well as well as finches To sum up 15 volumes of Arnold Toynbee, "What goes round comes around.

The current management/systems fiasco in health care cannot last. It just seems too tough to wait it out. And it is not just the system that we would have to fight. Our profession will not unite because however bad it is there will be someone creaming the dollars off who does not want change. One of the things I have liked about this discussion in this place is that overtly or covertly no one seems to be bemoaning an assault on their personal wealth, just the service they want to (used to?) provide for patients

Your Man of the Hour will need to watch his back as well as his front. Some of my close friends who are wise members of the medical establishment have been counseling me lately as the rigours of trying to do the best for my patients in the face of cuts and bureaucracy. In bars in strange countries These are people who run successful growing units producing top research even in these times. The have listened for hours as I divulged plans of quitting or taking up terrorism. They have two messages. Don't quit. Don't turn away The frontal assault is not an effective tool in this particular historical cycle.

The enemy will isolate and burn. Whistle blower is their euphemism for tellers of truth in the 90s. The wise virgins will trim their lamps. And wait. Davis,writing in "The Human Costs of Managerialism" argues strongly that the medical profession can weather the storm if determined and united. Indeed,he believes that ONLY the medical profession can deliver the public from the bean counters price driven health care systems which assume "that economists have the answer to all the problems of human existence in their economic calculus of the value of life." Davis says a major factor in the success of a profession seeking to end the madness is to treat patients better. Most complaints about doctors are about manner not quality of care. The doctor must clearly reestablish herself as the advocate of the patient faced with covert rationing.

The next thing we need is good data on what is happening. It is tedious to document patients we refused or could not take or adverse events due to price control. But it is essential. Fisher's Third Law of Management is that you must have data,you must understand the limitations of your c database and be thoroughly conversant with the data base limitations of the bean counters. They must have no idea of the limitations of your database.

Armed with data we need to learn to use the media. Patients (voters) don't read the NEJM. The major rules with using the media is that they have to produce stories and you have a ward full of them. Look after them when they need you and you don't need them to get a store of gratuitous credits. No one repays favours like a journo. When you need them they will deliver. You can match the PR department or the political media machine. But only once or twice.

And then,as the man who stapled his testicles together said, "If you can't lick 'em, join "em. My survivor advisors tell me you must not meet the enemy head on but get involved in the processes. You and the bean counters have a vested interest in each others success. And by understanding the process you learn where the money is and whose car is outside who's place and build up an army of people who owe you favours not malice. My problem is I did that and can stand it no longer. And their favour ethic is not like the journos. But Sun Tzu in the Art of War emphasizes that a general is doomed if he joins battle without a thorough analysis of the strengths and weaknesses of the enemy. From the inside is the best place to get it. Sun Tzu has the answers.

We must fight a guerrilla war.

You will note if you re-read my blurb, I don't mention anything about quitting or turning away. I theorized that physicians are maybe not the ones to start the revolution. I might have been the one to jam a big monkey wrench into the system a few years ago. As previously mentioned, I have been in trouble for anti-establishment activities all my life, right up through my fellowship. Ake Grenvik still flinches when he hears my name. But in those days, I sat on orange crates, juggled debtors and dragged drunks off my porch in the morning. I had little to lose and I felt better about myself when I was in trouble. Now I have a few creature comforts and responsibilities and I have a lot more to lose by getting into trouble. Regretfully, I, and my ilk, have become soft and slovenly. We are not the ones to go to the wall and wail. "Had he been a younger dog....."

That is not to say that someone isn't available to do it with the right motivation. Perhaps not even physicians. Perhaps the general public could be educated to see what's happening here and supply the monkey wrench into the gears. Traditionally, it is extremely difficult for Federal Wonks to go against the public grain. They all vote. In addition, there is something to be said for generating power within existing systems to forge good deals. If you are really good at what you do, and you provide a service that is needed and necessary for the hospital, and they value that service....you're in a pretty good position to bargain effectively. There is some accumulating evidence that Critical Care is a valuable hospital commodity. Under the influence of full time critical care types, length of stay is reduced, mortality and morbidity are reduced, the number of expensive specialists perched on foots of ICU beds daily are reduced, the public DEMANDS effective ICU care.

Malcolm says that we must fight a guerrilla war. I have some experience in that realm. David Galula contends that insurgency requires the following four prerequisites, all of which were met fully in VietNam:

1. A Cause: The corruption of the Diem-Nhu regime.

2. A weak Counterinsurgent: The Army of South VietNam, "trained" by the U.S. Army.

3. Good geographical conditions to hide insurgents: Mountains and Jungle.

4. Adequate outside support: Ho Chi Minh and financial support of Red China and the USSR.

If you extrapolate these conditions to Managed Care, it falls flat at the level of #2, #3 and #4, for reasons which should be only too obvious.

So perhaps our new age might be forging better negotiators rather than better terrorists.