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Monday, December 26, 2011

Doctors Say Obamacare Is No Remedy for U.S. Health Woes

From Forbes Online, 12/26/11

America’s doctors have conducted a full examination of the president’s health reform law — and their diagnosis of its effects on our healthcare system isn’t good.
Nearly two-thirds of doctors expect the quality of care in this country to decline, according to a new survey from consulting giant Deloitte. Just 27 percent think that the law will lower costs. And nearly seven of every 10 doctors believe that medicine is no longer attractive to America’s “best and brightest.”

Few people know more about our healthcare system than doctors working on the frontlines. Policymakers should pay heed to their indictment of Obamacare and revisit the disastrous law.

President Obama promised that his reform package would begin to stymie the out-of-control growth in the cost of American health care. He pledged $2,500 in health insurance savings for the typical American family.

But doctors don’t buy it. Only one quarter feel that Obamacare will reduce health insurance costs for consumers. Nine out of ten posit that insurers will raise premiums for employers and individuals.

They have good reason to doubt Obamacare’s cost-cutting potential. Healthcare spending is expected to reach $2.7 trillion this year — or about $1 of every $6 spent in our economy. By 2020, health spending will account for a full fifth of America’s GDP.

That increase is in large part thanks to Obamacare. Instead of relieving high insurance premiums, the nonpartisan Congressional Budget Office estimates that American families in the non-group market will see their premiums rise $2,100.
They’re already trending higher. According to the Kaiser Family Foundation, average family premiums in 2011 topped $15,000 — a 9 percent increase from 2010. Prior to Obamacare’s passage — from 2009 to 2010 — premiums went up just 3 percent.
In April 2010, Richard Foster, the Chief Actuary of the Centers for Medicare and Medicaid Services (CMS), concluded that American spending on health care through 2019 would be $311 billion higher than if the law had never passed.

Even with all that additional money flowing through the system, doctors don’t think that the quality of care will improve. Half of all doctors believe that access to care will diminish because of hospital closures prompted by health reform.
Further, nearly 70 percent of doctors believe that long wait times will plague emergency rooms. A full 83 percent of physicians foresee increased wait times for primary care appointments.

That’s in large part because Obamacare is expected to extend government-subsidized insurance coverage to many folks — even as the supply of providers remains relatively constant.

The United States already faces a shortage of primary-care doctors. Medical schools today produce one such physician for every two our country needs. By 2019, the American Academy of Family Physicians warns that the United States will be short 40,000 doctors.

Expanding insurance coverage to millions more Americans won’t do much good if they can’t get doctor’s appointments. Physicians believe that their ability to provide quality care will be further strained by the law’s attempt to change the way they’re paid — from a fee-for-service basis to a vaguely defined system of paying doctors based on patient health and outcomes.

Nine out of ten physicians fear they will receive inadequate payments and endure higher administrative costs. Fewer than a quarter of doctors expect their paperwork requirements to ease up. Time spent wading though paperwork is also time no longer available for actually practicing medicine.

American doctors’ negative view of Obamacare is telling. Proponents of the law may claim that their griping is misplaced, but as Paul Keckley, Ph.D., the lead author of the report explains, “Understanding the view of the physician is fundamental to any attempt to change the health care model.”

In other words, if physicians aren’t on board with Obamacare, it won’t work. A law that hinders the practice of medicine, obstructs access to care, and costs Americans more is clearly not the right remedy for what ails us.

Sally C. Pipes is President, CEO, and Taube Fellow in Health Care Studies at the Pacific Research Institute. Her next book — The Pipes Plan: The Top Ten Ways to Dismantle and Replace Obamacare (Regnery) — will be released in January 2012.

Sunday, December 25, 2011

Can we really afford Obamacare?

Since Massachusetts instituted Romneycare, the cost, per patient, of healthcare has risen steadily to over $9400.00 per person compared to a national average of about $6800.00. Now, it doesn't take a rocket scientist, a doctor, or an healthcare economist to figure out that when you mandate everyone to have insurance, the incentive for personal responsibility is lost and people will seek and demand more as well as more expensive high tech care of which most is not needed.

Sadly, most people will read this and just shrug...

Share and repost if you believe we cannot afford Obamacare!

CDC issues new alert for new R1P1 Virus


The CDC has released an urgent advisory to physicians and other healthcare providers warning about a cluster of small epidemics of a serious viral infection that has traditionally been a virus with relatively low virulence and with small, but characteristic spikes every 4 years or so.

Scientists from the CDC are calling this virus the R1P1 virus which is a politico virus that is similar to the polio virus in that it primarily infects the nervous system. Unlike the polio virus which primarily affects the peripheral nerves, the politico virus causes widespread damage in the brain manifested as chronic encephalopathy.

Infection with this virus causes a very characteristic syndrome characterized by a sudden and permanent loss of ability to engage in higher cognitive functioning or reasoning and patients affected are characteristically delusional and paranoid and engage in curious behavior including echolalia (the repetition of words or phrases by a patient of words addressed to him), obsessive rumination (repetitive regurgitation of inane phrases ), persistent dwelling in conspiratorial and paranoid thinking, and an obsessive and compulsive need to a-paul-ogize to radical Islam for American neo-nazi-fascism and intervention. The clinical syndrome is often referred to as pauli-encephalopathy and commonly called Ronpaulitis. It is very similar to another chronic brain-wasting disease (Mad Cow Disease) caused by a slow-virus and because of this similarity is often called “Mad Paul Disease”.

Researchers from the CDC are concerned about the increased incidence and virulence of this otherwise relatively harmless virus that in past years has infected relatively few people (less than 2-3%). The RP viruses are relatively common viruses and arise from a family of viruses called the "cult viruses", included in this family are the BO (B. Obamagotcha) virus, the DK (D. Koreshiae) and the JJ (J. Jonesensei) virus. Researchers at the CDC say they are not sure if it is a mutation in the virus from a R1P2 virus which is the most common variety to a new R1P1 virus, or if instead it is a relative decrease in host defenses brought on by concurrent infection of a similar virus called the BO virus. One researcher believes that the evidence supports a mutation rather than a general decrease in immunity in the population because of areas of sporadic epidemics in the US, such as Iowa, New Mexico, and Texas. While there is no cure for these viruses, researchers do say that they are preventable by engaging in common sense behaviors such as
thinking and avoiding certain books (The Revolution: A Manifesto, End The Fed, etc), documentaries (Conspiracy Theory with Jesse Ventura), or movies such as George Orwell’s 1984 or JFK and the Manchurian Candidate. While, most people have a robust and natural defense against the negative and irrational cerebral influences of this genre of work, it is thought that exposure and infection to the R1N1 virus renders this natural defense weak or even non-existent.

Doctors at the CDC claim they are working on a vaccine for this virus, but do not expect to see a vaccine come to market until after November of 2012 at the soonest and caution that it may take several more decades before a cure or vaccine are found.

Doctors, healthcare workers, and the general public are asked to contact their local health departments and/or the CDC if they have become exposed to the virus or know of anyone that has. Since there is no cure, this would be strictly for demographic and research purposes. (From Neuter's Medical News Service)

Iowa Kool-Aid and How to Form a Cult

I was surprised to see the results of the Fox News Poll showing Ron Paul leading in who the pollsters thought would win the Iowa caucus vote. While, I consider myself a conservative and lean more towards libertarianism, I am nonetheless, quite frankly concerned about the possibility of Ron Paul winning the primaries and--God forbid--possibly becoming president of the United States. My concern comes as a fellow physician who believes that Dr. Paul suffers from a real psychological disorder characterized by megalomania, narcissism, delusional thinking, paranoia, antisocial characteristics, and (abnormal) feelings of persecution. Now, I am not a psychiatrist, but I did minor in psychology as an undergraduate and most physicians have been educated in the behavioral sciences and have been trained to diagnose common psychiatric disorders. Furthermore, it is estimated that the incidence of Narcissistic Personality Disorder occurs 34 times more often in medical doctors than in the general population.

Over the last several weeks, I have been studying Dr. Paul as well as his followers through his television appearances, his letters (and Newsletters), social media, and video clips from You-tube and have noted a very disturbing pattern of Dr. Paul showing all of the psycopathological characteristics of a genuine "cult leader" and his followers showing all of the characteristics of a cult.

I have studied cults and their leaders and have outlined the "five basic
rules" of being a cult leader. I have also indicated the psychopathology associated with cult leaders as they form their cults:

The number one rule of a cult leader is to polish and cultivate a persona that you--and only you--have been chosen, anointed, or have achieved spiritual, political, or intellectual enlightenment above all others. This shows features of megalomania, delusions of grandeur, as well as narcissism.

1. Dr. Paul has tried to cultivate this persona for over 30 years as the “outsider” and enlightened one within the “Washington establishment”.

2. Dr. Paul has publicly stated that while he believes in term limits, they do not apply to him because (paraphrasing) “there is no one good enough to bring in to replace him”.

3. In 2010, Dr. Paul commented to his wife that he would run for President in 2012 “if things were happening so quickly and fast in our country and we were in a crisis period…and needed somebody…with the knowledge he as, he would do it”.

4. Dr. Paul presents in interviews as haughty and stern and seems to be lecturing rather than engaging in conversation.

The next rule is to appeal to the disconnected, disenchanted, and disaffected in society who are often intellectually, politically, and emotionally immature (i.e., younger people)and convince them that while you have been “chosen” (or more likely self-selected) you are (almost) human just like them and can empathize with their disenchantment and discontent. This shows more tendencies of narcissism and ego-feeding by someone who sees them self as inherently better than others, but with a need to surround one’s self with those less fortunate or less “enlightened”—a “savior complex”, if you will. Often times, the empathy and compassion shown to the acolytes is not genuine (which is a feature of antisocial personality) and is only used for the ulterior motive of personal gain in sex, money, or power (or sense of superiority) or combination thereof.

1. Dr. Paul has always had a relatively small number of fanatical followers who have mostly been drawn from younger people in society. He routinely targets schools,
colleges, and other events where younger people tend to be.

2. His “populist” message today resonates with many, besides young people as social, geopolitical, and economic turmoil are perceived to be worsening and more and more people become disenfranchised, disenchanted, and discontent.

3. Dr. Paul’s ploy of not accepting Medicare payment for his Medicare services or a congressional pension—while on the surface seem like noble gestures—are really means to portray himself as “one of us” and morally higher than his colleagues.

The third step is through indoctrination, coercion, repetition, and/or isolation to exercise mind control over your flock of followers by relieving them of their ability to think rationally (usually by not allowing them to test your theories or have access to “the outside”)—but not emotionally—while simultaneously convincing them that your ideas—while plausible (but generally at the far fringes of mainstream thought) are the “light and the truth”. This shows more elements of antisocial ego-building in that the leader is now getting others to surrender their will and rational thought against deep seated norms of the self and/or society while they align their thinking towards that of the leader.
Furthermore, this shows the disordered or delusional thinking of the leader who generally has delusional thinking of the world and how it operates and he or she is the only one with the power to fix it.

1.Dr. Paul plays on the emotions of his followers by carefully crafting plausible—and easy to understand-- (but highly improbable and at the fringes of mainstream thought)scenarios out of complex geopolitical, political, social and economic issues
that are at “top of mind” of our society and that tug at some of our most basic
interests (individual freedom, economic freedom, nationalism, sanctity of life,
torture, and war) and evoke very basic human responses such as fear, anxiety,
anger, disgust, and etc.

2. Dr. Paul’s views on national defense, monetary policy, isolationism, and constitutionalism are considered by most to be outside of the mainstream of rational political, social, and governmental philosophy.

3. Dr. Paul has consistently repeated his messages over 30 years and as noted above, tends to target younger followers who are easier to indoctrinate.

The fourth rule is to proselytize not only your “enlightened philosophy or beliefs, but also to spread forth the word that while you and your followers are “the enlightened or chosen ones”, there will be naysayers and those that will persecute you and the movement. This clearly shows the elements of paranoia and persecution by the non-believers.

1. Dr. Paul and his followers are very defensive when challenged on the issues and their beliefs. Instead of engaging in earnest discourse, they tend to attack and accuse the “non-believer” as persecuting them for their beliefs or of being ignorant and unenlightened in their philosophy.

2. Dr. Paul and his followers display a common paranoia and decry a “conspiracy” of the right, the political elite, and the left against them and their “lofty ideas that will save America”.

3. Dr. Paul has consistently offered the explanation that others are simply “out to get him” by taking “tongue-in-cheek comments out of context” and things that were written in his newsletters (but purportedly not authorized or written by him).

4. Dr. Paul comes off as defensive and angry when challenged in interviews and becomes condescending.

The fifth and last rule is to convince your followers that it is only through blind faith and rigid adherence to your philosophy—no matter how foreign it may be to self or to society—that that blind adherence or “loyalty” is the only path to salvation, redemption, or the reparation of the “perceived” ills of society. This is more antisocial ego-building and the tightening of control over the flock.

1. Dr. Paul and his followers play the same monotonous drum beat about “smaller government”, defense of our borders,monetary reform and fiscal responsibility, “stop the wars”, and national isolationism over and over again like a Gregorian chant and mantra in a blind and stubborn adherence to their fringe philosophy that is the only path to saving America despite practical, rational, philosophical, and real world
evidence against and “common sense” opposition to their “zany” ideas, Messianic
messages, and Utopian philosophies.

Some authors would add another step which is to construct a “doomsday scenario” for your followers, such as “the end of the world, World War III, or economic collapse as the great incentive to motivate the followers to adhere to and spread your
This, again, would show delusional thinking as well as narcissistic thinking, especially if the leader and his or her followers will be the only ones saved from the impending calamity.

1. Of course we are all aware of the “doomsday” prophecies of Dr. Paul considering our economy and its impending collapse with hyperinflation if we don’t get rid of the Fed.

After considering this, and seeing Dr. Paul’s rise in the Iowa polls, it makes me
wonder what they are doing out there in Iowa. It seems to me that maybe they are mixing a little Ron Paul Kool-Aid with some fermented corn!

Saturday, December 17, 2011

"Arm chair economists" vs MD/MBA and Expert in Healthcare Economics

I have read with amusement the letters to the editor in today’s (12/17/2011) Albuquerque Journal criticizing Dr. J. Deane Waldman’s recent editorial regarding out of control health care costs and the government’s role in regulating and/or contributing to those costs. It is interesting that all three letters published were all critical of Dr. Waldman’s analysis with no counter opposing view(s) supporting his analysis. I don’t know if that means there were no letters to support Dr. Waldman or if the Journal simply chose not to include any letters that supported his views.

Regardless if there was any supportive letters sent to the editor, it is both interesting and amusing to see three non-medical (and assuming, non-health care economics) professionals—unless one counts “45 years experience as a health care advocate” as qualifying as a health care professional—trying to rebut the thoughtful analysis of not only a practicing physician who has practiced for more than 2 decades within our “sick system”,but is also an MBA who is a published author and expert in healthcare economics and reform.

It is obvious from the reading of all three letters that the basis of their rebuttal is not based on any real facts or data from scholarly journals in medicine or economics, but rather simply on personal political ideology and opinion. All three letter writers obviously espouse a more liberal “more government is better” philosophy towards healthcare—vis-à-vis “Obamacare”-- and two of the letter writers ignominiously attempt to discredit Dr. Waldman’s analysis as merely the musings or political ranting of just another ill-informed or unenlightened “conservative”.

Regarding the first letter by Mr. Richard Valdez, he somehow manages to shift the argument that more government regulation is more or less cost efficient based on the merits—or lack of—of governmental bureaucratic efficiency , instead arguing for the benefits of more government regulation in healthcare in order to improve patient safety. In other words, he is trying to compare apples to apples, but using oranges as an example. On top of that,he insinuates that Dr. Waldman just magically pulls his data (of 40% of healthcare expenditures not going to pay for direct patient care) out of the air if not from a “conservative think tank” while offering his own simple statistic from the CDC and Institute of Medicine (which by the way is a liberal think tank) of “100,000 to 135,000 deaths annually due to doctor and/or hospital error”. Now, did I miss something? I thought we were discussing money and bureaucratic efficiency/inefficiency here and not the number of potentially preventable patient deaths per year attributable to medical errors. What does one have to do with the other? I’m deeply sorry that he has lost two sons, but his argument that more government spending or regulations would have saved them may or may not be true, but have absolutely nothing to do with the argument that the government can or cannot be more efficient in managing healthcare!

While this letter is meant to offer a critique of the letters criticizing Dr. Waldman’s analysis and not a separate analysis of how we can best prevent medical errors in healthcare or what the government’s best role is in preventing medical errors, I do want to point out—using Mr. Valdez’ own statistics—how easy it is to pick and choose random statistics disingenuously to support one side or another of an argument. While Mr. Valdez correctly contends that there are anywhere from 100,000 to 135,000 (actual range is 85,000 to 195,000)deaths annually attributable to doctor and/or hospital errors, he conveniently fails to indicate that number one, these are classified as “potentially preventable deaths” and number two, that these potentially preventable deaths represent an extremely small fraction (0.00005%--using the higher number of 200,000) of the nearly 1 billion (995 million) doctors visits, outpatient clinic visits, ER visits, and hospitalizations (CDC data) seen each year!

You don’t have to be a "Black Belt” in Six Sigma --an extremely rigorous business ideal advocating for near perfection or 99.99966% error free processes—to see that in medicine, we get pretty damn close! Now as a physician and a father-- and a healthcare consumer-- I understand that we are talking about human lives here and not the manufacturing of ball bearings and that even 1 preventable death due to medical error is tragic and regrettable, but from the dawn of civilization, we have never been, currently are not, and never will be perfect in medicine or in any other human endeavor!

Mr. Raymond Schall and Mr. Byers both just simply spout standard democratic party line demagoguery in their justification for and defense of “Obamacare” and increased government involvement in one of the most personal aspects of our lives without providing any real or objective data or logic to buttress their criticism of Dr. Waldmam’s analysis. Mr. Schall tries to
also pick and choose some “statistics” to bolster his support of “Obamacare” by citing that the “Health and Human Services recently released their long awaited rules requiring insurance companies to spend at least 80 to 85 percent of their revenue on actual patient care. What he failed to mention is that in the United States, most private insurance companies spend about 6 to 11percent of revenues on “administrative costs” and 89 to 94% on “patient care costs” (multiple sources). He also did not mention that from at least 2000 to 2010, Medicare consistently has spent 19 to 31% more on true “administrative costs” than private insurance companies. He also tries to tout the benefits of “Obamacare” by stating that “more than 100,000” New Mexicans have “received free preventative health care” and “more than 18,000 students have received primary and behavioral healthcare” because of “Obamacare”.

Now Mr. Schall obviously has never heard of or does not believe in the 1st principle of economics which basically states “there is no such thing as a free lunch”. He uses the word “free” as if “the free market tooth fairy”—to borrow a trite little phrase from Mr. Byers (the 3rd letter writer)—suddenly dropped the money into the government coffers to pay for the “free care”! Excuse me, but just because the patients received “free” or discounted health care doesn’t at all mean that it was “free”—somebody(you and I—and not the tooth fairy) in the form of increased taxes and or both increased premiums has to pay for that “free health care”! Beyond that, the medical providers providing the “free care” do so at a deeply discounted government mandated rate that often is below the amount required to sustain a viable practice!

Finally, Mr. Doug Byer’s letter is nothing more than old and tired progressive-socialist and “new” OWS dogma lamenting the evils of capitalism and free markets thinly—as well as feebly--disguised as an attempt in intellectual discourse.

I conclude my critique of the letters to the editor with some rather interesting “statistics” to ponder:

1. There are approximately 1800 pages each in both Harrison’s textbook of Medicine and the American College of Surgeons textbook of Surgery which could be considered the "bibles” of Western Medicine and Surgery and which represent the collection of
at least 3000 years of medical and surgical science and knowledge. This compares to 1000 pages in the Patient Protection and Affordable Act (aka “Obamacare”), 670 pages in the HIPPA regulations, and over 132, 000 pages of Medicare rules and regulations collected over the last few decades (this does not include the various state and local rules and regulations regarding the practice of medicine in States and local localities)!

2. There are approximately 650,000 practicing physicians and surgeons in the United States and it is estimated that for every physician, there is 2 to 5 or (1.2 to 3.25 million) “non-medical administrative” workers (most of them Federal and State employees) per doctor “administering healthcare”!

3. The Medicare Trustees have projected that Medicare (which administers to approximately 30.5 million Americans) will be bankrupt by 2024 at current spending projections and somehow we want to expand that government bureaucratic behemoth to cover 10 times that much? This is what a “real” doctor in health care economics has to say about that:

“Contrary to the claims of public plan advocates, moving millions of
Americans from private insurance to a Medicare-like program will result in
program administrative costs that are higher per person and higher, not lower,
for the nation as a whole.”

Robert A. Book, Ph.D., is Senior Research Fellow in Health Economics in the Center
for Data Analysis at The Heritage Foundation


John R. Vigil, MD

Dr. Vigil has a blog titled “What’s Wrong With American Healthcare Today;
The Musings of a Working Doc” and has been a practicing physician and surgeon for over 20 years. His interests in medicine are healthcare economics, improving healthcare delivery, and history of medicine and surgery. He has completed 1 year towards his Master’s degree in Business Administration at the Anderson School of Management, University of New Mexico.

Wednesday, August 31, 2011

Opiates and Pain Management; Pandora's Box

Opiates and Pain Management: Pandora’s Box

Today is National Overdose Awareness Day and an appropriate time to discuss the terrible epidemic of opiate addiction that we are seeing, not only in our community, but nationally as well. The statistics are staggering as according to SAMHSA (Substance Abuse and Mental Health Services Administration) there were 1.9 million prescription opiate addicts and another 600,000 or more heroin addicts in 2009 and the numbers are increasing. Accidental overdose has overtaken car accidents as the number one killer of young people 18 to 44 who are not only in their prime of life, but also the primary producers in our economy and society. It is estimated that overall, 24 million people in the US have an addiction and only about 1-2% are receiving treatment for their addiction.

I could easily write an entire paper on the staggering cost of addiction, not only in loss of human lives but also in economic costs to this country; however this paper is about the people affected by this horrible epidemic and not about statistics. There have been a number of stories and citizen comments recently in our news and newspapers about young people tragically dying of heroin overdose and doctors over-prescribing narcotic medication. This paper is written to try to bring some insight to the community of the scope of this problem, how we got there, and some possible solutions.

Sometime in the middle of the last decade, several national and international organizations, including the WHO (World Health Organization) drafted and adopted a Patient’s Bill of Rights that dealt specifically with pain management. Specifically and amongst other things, it stated that all patients “have a right to proper, respectful, informed, and non-discriminatory pain management and care”. Prior to this shift change in medicine, opiates had more or less been reserved to manage chronic pain only for patients with advanced cancers or other end-stage painful conditions. Apart from these patients, the only other use for opiates was generally for the short term treatment of severe acute pain postoperatively or for severe acute trauma. Following the lead of the national and international organizations, most state medical boards and societies adopted the Pain Patient’s Bill of Rights and Pandora’s Box was opened.

Since then, millions of patients have been treated and are being treated with opiate pain medication for a variety of conditions including headaches, chronic back pain, arthritis, fibromyalgia, and just about any other disorder that causes pain. While the overwhelming majority of these patients are being treated for legitimate pain by well-meaning, well trained, and legitimate physicians and are not abusing their medication or addicted, many of them do become addicted and/or dependent and a few obtain their medication illegitimately, by ruse or illegally. Unfortunately, there have been—and remain--more than a few unscrupulous and unethical doctors who have been more than happy to provide some of the latter “patients” with prescriptions for narcotic medication.

The opening of Pandora’s Box has produced a schizophrenic medical community with doctors under pressure to respect and adhere to the “Patient Bill of Rights” by providing legitimate patients with adequate and compassionate pain management on the one hand while feeling threatened or intimidated by the DEA and other law enforcement agencies if they chose to treat such patients. Another problem arises when all physicians know and understand that while the majority (more than 80%) of patients treated with opiate pain management will never develop an abuse problem or addiction, about 10% will ultimately develop an addiction with its attendant negative consequences—including risk of accidental overdose-- on those patient’s lives. Unfortunately for us, patients do not carry a sign with them that warn us that a particular patient will become addicted. Furthermore, since pain is a subjective and individual experience and is modified by emotional, physical, and psychological states, it is impossible for any physician to be 100% certain 100% of the time, who is legitimately seeking pain management and who is not.

By some of the reports in the news as well as some of the citizen’s comments, it would appear that there is a perception that most physicians are just “willy nilly” handing out prescriptions for opiates to just anyone who requests them without consideration of the consequences. As I have mentioned earlier and which have been documented in news stories across the country, I acknowledge that there are unethical and unscrupulous physicians who are prescribing for profit, but like the minority of legitimate patients who become addicted and cause problems to themselves and society, they are in the vast minority! In fact, statistics from SAMHSA indicate that in most communities, most “illegitimate” prescriptions are coming from only 1 or 2 doctors. Most doctors take their responsibility to their profession and society seriously and understand the risks of prescribing opiate medication. We also understand that the majority of people prescribed such medication will also be responsible and never develop a problem with it and we are constantly weighing the risks versus the benefits of prescribing such medication to each and every patient. It is inevitable that some of us will be duped by some “patients” and it is also inevitable that some legitimate patients will develop an addiction and that is the risk we take while Pandora’s Box is open.

Another common misperception is that many teenagers and young people are becoming addicted to opiates obtained from doctors. There are very few indications to treat a young person with opiate medication and most physicians are hesitant to prescribe these medications to teens and young people except in cases of moderate to severe pain from orthopedic or operative trauma. Statistics from SAMSHA and from my personal experience as an addiction specialist, most teens and young people (55%) report that they are getting their opiates right from home (friends or family), 17% report getting them from one doctor, and the rest from the street. Of those that reported obtaining their medication from friends or family, 80% of the friends or family members reported getting their medication from only one doctor.

So what can we do about Pandora’s Box? According to legend, once it was open, there was no way of closing it and I do not believe that there is any way of closing our modern day version of the box. However, the one thing that remained in the box was hope and it with hope that we can possibly change things at a variety of levels including personally, professionally, and legislatively to effect positive change in our communities and society at large to combat this insidious and horrible epidemic that is claiming the lives of our youngest and most productive individuals. Every time one of our young people dies from an overdose, it robs us all and our society of a “what if”—what if that person was going to be the next doctor to cure cancer or addiction, a great actress or actor, singer or athlete, or the next CEO of a great company, or even the next President.

While I do not profess to have all of the answers to this complex and vexing problem, I do have some suggestions, some of which will undoubtedly bring much scorn and criticism upon me from colleagues and others. I will outline these suggestions from a personal to professional to a legislative order.

Personally, as individuals we must all become aware of this insidious epidemic and must educate ourselves—and our children-- about the risks and dangers of opiate addiction when given these medications, even for short term use. As parents, we must educate ourselves to the signs and symptoms of addiction so that we may intervene early and decisively should we suspect our children or loved ones of developing a problem or experimenting with opiates. If we are obtaining and using opiate medication we must take measures to safeguard our medication and keep them out of the reach of children and inquiring minds. We can become advocates in our schools and our communities, becoming involved in groups and organizations, such as the Heroin Action Committee, that spread the word about this problem. Lastly, we must learn and understand that addiction is a disease and should be treated like a disease without the stigmatization that surrounds it and which stands as a barrier to many of those who would otherwise seek treatment.

At a professional level, we must take our heads out of the sand and acknowledge the epidemic of opiate addiction that the opening of Pandora’s Box has caused. We must keep up to date on the standards of care for the treatment of chronic pain and we must also keep up to date on the advances that are being made in the non-opiate management of chronic pain as well as the advancements being made in addiction medicine. We too, must divest ourselves of the cloaks of superiority and ignorance and recognize addiction for the disease that it is and not the old stereotypes we might still believe. We must accept our part in this epidemic and be more diligent about truly doing risk analysis every single time we write a narcotic prescription, including opiates, benzodiazepines, and medication for ADD. We must recognize our educational and training limitations and refer those patients requiring complex psychological and concomitant pain management to appropriate specialists. It is our house where Pandora’s Box came from and we must clean our house or others will clean it for us and ultimately, the patients and society will suffer.

At a legislative level, which must occur at both the state and federal levels, there are several things that can be done. First of all, hydrocodone and tramadol should be made scheduled II narcotics and all scheduled II narcotics should be controlled and prescribed only by appropriate specialists or physicians who have demonstrated interest, experience, and proficiency through conferences, courses, and continuing medical education in pain management—as well as addiction-- to their respective state medical boards or licensing agencies. It is interesting that I must demonstrate proficiency to apply for a license to prescribe Suboxone which treats addiction, but I have no restrictions whatsoever to write for all the drugs that cause addiction! For those specialists that may often treat acute severe pain, such as surgeons, orthopedic surgeons, or ER/Urgent Care physicians, strict limits should be made with respect to amounts written for and duration of treatment for all scheduled II drugs. All states should be mandated to have a reporting mechanism through the pharmacy boards where all physicians should be mandated to access and report to before prescribing scheduled II medication. On a broader level, we must enact legislation that shifts the emphasis from punishment to prevention and treatment for those that struggle with addiction. We should encourage and expand dramatically the number of doctors and midlevel providers who wish to provide outpatient opiate addiction treatment with Suboxone. As a society, we too must understand that addiction is a neurobiological disease manifested by abnormal behavior, not abnormal people voluntarily engaging in harmful and bad behavior!

Pandora’s Box may be open, but by coming together as citizens, professionals, and policy makers, we can perhaps reopen the box and bring hope to our communities and to society.

John R. Vigil, MD

Saturday, February 26, 2011

Why Healthcare Cannot Be a Right--In a Free Society

There is a proposed constitutional amendment in our state (New Mexico) to recognize Healthcare as a basic human right. Dr. Bruce Trigg, a local physician and colleague wrote an editorial in our local newspaper titled "Make Healthcare a Right For All". The following is my response:

I have read my esteemed colleague’s (Dr. Bruce Trigg) editorial today (2/25/11), titled “Make Health Care a Right for All.” While I have the utmost respect for Dr. Trigg, I must answer with the counter argument that health care is not a right-- in a free society.

This nation was founded on the principle of “self evident truths” that each of us as individuals are born equal (not that we should share in all equally) and “endowed’” with “certain unalienable rights”, including the right to “life, liberty, and the pursuit of happiness”. Nowhere did our founding fathers mention “health care” or “good health” as a right, neither in our Declaration of Independence nor in our constitution or its Bill of Rights.

Now some would argue that in 18th and early 19th century America, “Health Care” was nothing to brag about and certainly, nothing to pursue as a fundamental right for all citizens. Others would argue that it was simply an oversight that the founding fathers did not include our health as a fundamental right. I would counter the first of those arguments by asserting that many Americans would travel back to Europe for their “health care” which had to be extraordinarily expensive and inconvenient and yet, there was no clamoring to have the fledgling American government, or rather, its citizens pay for such care. As far as the second argument goes, it is incredulous and inconceivable to consider that considering the collective wisdom of our founders who included Benjamin Rush and other physicians, they would have overlooked something as important as a basic and fundamental human right.

I believe that it was with foresight from our founding fathers that “health care” as a right was purposely excluded as a basic and fundamental right. Unlike, our current politicians, our forefathers were well read and versed in history, philosophy, law, economics, and theology and understood the dangers of the government picking and choosing certain rights arbitrarily and compelling the citizenry to pay for such rights. They understood human nature and man’s natural tendency to want and desire what others have and he doesn’t have and they understood how that very human nature could be exploited by politicians and tyrants for political expediency and political power by providing those things as “rights”.

They recognized that man could conjure up an endless list of needs and desires and rationalize any one of them or all of them as being indispensable as basic human rights. Yet, they carefully selected only three basic “unalienable rights” or “natural rights”, none of which another man could provide to another nor could be compelled to pay for or provide to another. These rights are negative rights in that the right is not in the power or the purview of the government (or fellow citizens) to provide such rights, but rather places in the government the power and responsibility to protect such rights from being taken away from us. The government nor our fellow citizens cannot give us or ensure us life, liberty, the pursuit of happiness-- or good health!

Our government may only protect our rights from such things being taken from us and it is our individual responsibility to respect the rights of others and not take such rights from each other, but nowhere in our constitution is it stated or expressed that our government must provide us with anything or compels us to provide our neighbors with anything! They understood that to compel us to provide for the needs and wants of our neighbors would be antithetical to the very principles this country was founded on and for which we fought a war of independence for: That no man should be in servitude to a tyrant, a tyrannical government, or to each other and that no man should be beholding to or dependent on another man or government for his life, liberty, or pursuit of happiness!

Now some would argue that the Bill of Rights and subsequent amendments to the Constitution is where we derive our positive rights from, or those rights that by “social contract”, obligate us or our government to provide us with certain “rights” pertaining to our “general welfare”, yet the first ten amendments, or the “Bill of Rights” were added to further delineate—and limit—the power of the government with respect to both protecting our natural rights of life, liberty, the pursuit of happiness and the right to attain and own private property as well as to define and specify certain liberties, such as the freedom of speech, the freedom to keep and bear arms, and etc. Again, nothing in the Bill of Rights or subsequent amendments explicitly or implicitly allows for or compels the government to provide the citizenry with a minimum standard of welfare or for the citizens to provide for the general welfare of each other for to do so erodes our individual freedoms and places us in the servitude of our government and/or our fellow citizens.

Dr. Trigg in his essay asks “why can’t we guarantee that everyone has medical care on the same basis that we provide police and fire protection and universal free education”? The answer is that the provision of police and fire protection are governmental institutions specifically created and empowered solely to protect our natural and property rights. They cannot provide us with any material needs or desires nor can they deny us or take away from us our property, our lives, or our freedom. With respect to providing “universal free education”, nowhere in the Constitution is it mandated that we all be provided free education. Education from K to 12 is compulsory by state statutes and certainly is not “free” in that we all pay taxes to fund our public education. Access to higher education is protected by law, again, as a negative right only, in that no one, including the government can prevent us access to education—as long as we have the means and money to pay for it!

So far, I have made the argument that our Founding Fathers and Framers of our Constitution purposely excluded “health care” and an endless list of similar human needs and wants as positive rights based solely on a moralistic philosophy that to compel the government or the citizenry to provide for such rights would create the hypocritical and antithetical situation of protecting our freedoms and pursuit of happiness while at the same time placing us into involuntary servitude to our government and/or our fellow citizens. Although I believe that such moralistic and enlightened thinking was behind the decisions of our Founders as they framed and penned our Constitution, I also believe there were more practical considerations as well that influenced their thinking.

Besides being great moral thinkers and products of “the enlightenment”, our Founders were also businessmen and pragmatists and understood that the provision of most goods, needs, wants, and services—including health care—to the citizenry was best, most fairly, and most efficiently accomplished through the time-honored system of free markets. They understood from Adam Smith that free markets are the engines that drive democratic economies and the most efficient way to provide scarce resources to the greatest number. They also understood (unlike modern politicians) that the “invisible hand” of the free markets worked best unfettered and unrestrained by the “heavy hand” of oppressive government, burdensome bureaucratic regulations, onerous taxes, or union extortion.

Dr. Trigg is correct in asserting that a substantial number of our population already receives “[free] medical care either provided directly by the government (VA, Military, Indian Health Service, etc) or paid for by the government (UNM, Medicaid, Medicare, etc)”; however, he fails to mention that, for the most part, care in those systems, is grossly inefficient, very costly, and burdened by layers and layers of costly and onerous government bureaucracy and would best be provided by independent and competing practices in a free market system!

Dr. Trigg states that the proposed state amendment making health care a human right “paraphrases the words of the late Cardinal Joseph Bernardin” who has called since the 1990s for our government to recognize healthcare as a human right which government must “take responsibility” for. That is an interesting proposition from a religious spokesman from a religion that from medieval times has assumed the responsibility of providing access to healthcare and healthcare directly, through charity and charitable hospitals to millions and millions of sick souls! The Catholic Church and other religions have plenty of assets and money, if they believe healthcare is a right, then let them bear the burden of responsibility of providing it! I’m sure that religious leaders would no more appreciate government fiat compelling them to assume the responsibility of providing healthcare to each and every citizen anymore than any free man or woman wishes to be compelled to assume such responsibility!

I am not arguing that access to healthcare is not a right and I do not believe that our Founders believed that access was not a right; they correctly believed that “healthcare” in and of itself is a service and best provided through the marketplace. Every American has access to healthcare right now and our government has enacted statutes to prevent anyone or any government entity from barring us from such access to healthcare and that is the extent of government involvement that our sage Founders purposely wrote into the Constitution. Unfortunately, from Roosevelt, to Obama, modern day politicians have completely disregarded the thought and intent of our great Founders and have transformed an “age of enlightenment” to an “age of entitlement”.

Now before, I am accused and nailed to the cross as an uncaring and self-serving capitalist or hate-monger, it should be known that I have started a free-clinic for migrant workers in Ohio in 1995 that still operates today and I open my clinic as a free clinic in the South Valley to uninsured and underinsured people every 1st and 3rd Sunday of the month. I also have never turned a patient away from any of my clinics because of their inability to pay and every day I provide free or discounted care. As a physician, I took an oath of voluntary servitude to my fellow man, but, as an American, I must resist any call from my government or otherwise well-meaning citizens for my indentured servitude to them, for I am a free man in a free and democratic society!

John R. Vigil, MD