Medicare,The AARP, and Sutton’s Law

August 31, 2009

There was a time when Sutton’s law was commonly taught to medical students, but its use has declined as has the notoriety of the bank robber (Willie Sutton) for whom it was named. Sutton is alleged to have said that he robbed banks because that’s where the money is; he denied saying this. It’s meaning is that you should work on the part of the problem that’s most likely to give you the results you’re after instead of wasting time and money on the periphery.

The AARP seems to be ignorant of this basic principle of action and interest. They just sent out a mailing urging their members to contact their Senators to support healthcare reform.  They want “Congress to ensure all Americans have access to quality, affordable health coverage by:”

1. Providing more prescription drug coverage to millions of Medicare beneficiaries by narrowing or closing the benefits coverage “gap” (or Doughnut Hole) in the Medicare Part D program;

2. Ensuring all people have a choice of health care plans they can afford regardless of age or any pre-existing health conditions;

3. Making sure all Americans are free to choose their doctor and to follow the course of treatment their doctor recommends;

4. Strengthening and improving Medicare and ensuring that Americans ages 50 to 64 have a choice of health insurance plans they can afford;

5. Improving quality and reducing medical errors so all Americans have the peace of mind that comes with good health care;

6. Ensuring that all Americans have the security of knowing that if they lose a job or experience life’s other ups and downs, they will be able to get coverage;

7. Reducing the cost of health care by weeding out waste, fraud, abuse and inefficiency that leads to unnecessary and more costly care; and

8. making sure some individuals have a choice to receive the care they need at home rather than in a more costly institution.

That’s some list. I suppose that the AARP thinks its membership is so addled that the won’t be able to see how muddled and utopian the thinking that conceived this list is and that they’ve forgotten who Willie Sutton was. Remember the goal is access to quality and affordable health coverage. If we’re going to save money on medical care we have to go where the money is. It’s not in the Boy Scouts; it’s in Medicare. If the AARP gets its way Medicare recipients are going to get screwed. Consider bullet #7. Where’s the inefficiency and and unnecessary care that’s slated for the trash?

Medicare fraud is already illegal and needs no further legislation. The waste and inefficiency in the system (and there’s a lot of it) is tattooed onto Medicare and is likely to be reduced by no other process than the delivery of less care. If it were relatively easy to discard waste and inefficiency we’d have already done it. It too would require no new laws.

By the way, did you see a bullet advising tort reform? No?  Neither did I. Figure out why yourself.

Consider point #1. It will raise costs. 75% of Medicare recipients had prescription drug coverage before the Part D program was enacted. I suspect many of these seniors will drift out of private programs into the public one as time passes. So we’re going to have to  make up the cost of this part of the plan somewhere else. Of course we could nationalize the pharmaceutical industry. If cars why not drugs?

Point #2 requires (though it avoids saying so) that health insurance be mandatory for everyone. If it were optional healthy people would wait until they got sick to buy insurance. Point #4 is redundant; it duplicates #2. AARP membership starts at age 50 so I guess they thought they’d throw the point in to remind their younger members that they’re thinking of them.

Number 5 is admirable. The medical profession has been trying to do this for generations with some modest success. It would be great to do better but I doubt the Federal government will improve on our efforts.The best way to make no errors is to do nothing.

The last point is interesting. The cost of taking large numbers of patients out of nursing homes and other custodial institutions is difficult to calculate. With all the nursing and ancillary support necessary to do a decent job I suspect costs would go up.

It’s nice to be public spirited, but the AARP seems to desire a plan that will inevitably result in less care for Medicare patients. It may even be better for the country to spend less taking care of the old, but an organization that claims to represent this population should back a plan that preserves their interests. Let some one else lobby for restricting care to the elderly.

The AARP has not officially endorsed a specific piece of legislation, but their points seem to straight out HR 3200. When you look at the totality of their desires you can’t tell if A. Barry Rand the AARP’s CEO whose signature follows these bullets is naive or devious. Nevertheless, he proposes a system that has yet to work anywhere and which is so full of contradictions that even Thomas More couldn’t figure out how to construct it. Regardless, he and anyone else interested in building a medical Utopia should read Isaiah Berlin’s essay The Pursuit of the Ideal. The AARP seems to have become a partisan organization masquerading as an impartial organization devoted to the well being of older Americans. When an organization loses touch with its members it future is ominous.

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Giuseppe Di Stefano Sings Three Songs

August 30, 2009

The clip below presents the late  great tenor singing three songs. His says that he’s going to sing thee Sicilian songs, but  the clip is obviously edited as he sings one Sicilian song, then a Spanish song, followed by a short version of “Core ‘ngrato”. Pippo was 28 when this performance was recorded. The pianist is Ivor Newton.

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Diagnosis of Diabetes

August 29, 2009

The diagnosis of diabetes mellitus is officially based on measurement of fasting blood sugar or two hour post glucose blood sugar. Unofficially many physicians have used HbA1c to diagnose the disease. A few years ago I was on a panel discussing hypertension. A difficult case was presented. There was a question as to whether this patient was diabetic. I asked what his  HbA1c was. One of the panel’s members said in an unkind tone that diabetes was not diagnosed by that test, that an elevated blood sugar was required. He was correct. My reply was that this was so because a bunch of guys had gotten together is a dark room and decreed this criterion, but that any thinking physician would suspect diabetes regardless of the blood sugar if the HbA1c were 8%.

Well, now another bunch of guys have decided that a HbA1c of 6.5% or more is the preferred way to diagnose diabetes. The panel presented its advice to the annual meeting of the American Diabetes Association in June.  What’s changed? Nothing really. The panel just codified what many doctors have been doing for years.

Expert panels do things like this all the time. I’ve been on many of them and have watched with interest how a lot of very smart people can come up with advice that is not as smart as its membership. The reason for a panel being less than the sum of its parts is central to the human condition and applies to gatherings of any sort. There are always different ways to intelligently approach any problem. When a committee issues a report it will have to amalgamate the most conservative views with the most aggressive and include those in between. The result is often a dumbed down statement that offends no one (or if it gives offense is not enough to incite rebellion). The larger and more inclusive the membership of a panel or committee the blander its recommendations. This is what happens when a committee is truly knowledgeable and well meaning. Imagine the result when its membership is not fully up to speed or less than benign.

Of course reality eventually cannot be ignored and the truth, even if it’s been camouflaged, will sneak out. It’s been 30 years since any major change in the way we diagnose diabetes has been made. The panel’s findings have yet to be adopted by the ADA, though I suspect they will be endorsed. How long has HbA1c been used in diabetes ? – 40 years, though it was not proposed for use in monitoring glucose control in diabetics until 1976. Thus it may be that 30 years is as short a time as we can manage to catch up to some realities

The collective shaping of “reality” presents problems to busy physicians who lack both the time and expertise to evaluate the best regimens or diagnostic approaches to a vast array of diseases. Even if they can make a truly informed evaluation the malpractice implications of departing from guidelines (which morph into rules) often prevents them from independent action.

This problem, as suggested above, goes far beyond medicine. We don’t trust any individual to make an important decision totally on his own even if its its virtually sure to be right, yet committees have a hard time with focused reality. So we muddle through as best we can.

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Cenerentola at Glimmerglass

August 22, 2009


The Alice Busch Opera Theater is on the shore of Otsego Lake (aka as James Fenimore Cooper’s Glimmerglass). The austere but lovely 914 seat theater has housed Glimmerglass Opera’s productions since 1987. The company now presents about 40 performances of four works each Summer. On Friday August 21 Glimmerglass mounted its penultimate performance of its new production of Rossini’s La Cenerentola.

Joseph Colaneri

Joseph Colaneri

Glimmerglass is housed in such an idyllic setting that it would be worth a trip even if the company were mediocre. But it’s not. Cenerentola was about as good as it’s possible to get. The biggest reason for the success of this production was the electric conducting of Maestro Joseph Colaneri. The veteran conductor seems to have Rossini in his DNA. His pacing was perfect – crisp and taut. The great ensembles were focused and swift as a bullet. Rossini is not for sissies. He needs a tough guy behind the baton and that’s what he got in Colaneri – terrific. The orchestra was as good as its leader.

The singers were all unknown to me, but under Colaneri’s expert guidance they were at the highest international level.

Julie Boulianne

Julie Boulianne

Canadian mezzo-soprano Julie Boulianne had all the right notes and the right sound as well in the title role. She reminded me of Little Orphan Annie as much as she did Cinderella, but that’s of little import. What is important is that she was pert and up to all the role’s great vocal stresses. “Nacqui all’affano … Non piu mesta” the great scena that ends the opera was delivered with ease and finesse. Of course, the the theater’s intimate scale made things easier for the singers so it’s difficult for me to tell how she’d do in a setting as cavernous as the Met’s.

Her two wicked “sisters”, Clorinda and Tisbe, were effectively played by Jamilyn Manning-White and Karin Mushegain both members of the company’s young American Artist program. They were appropriately smarmy and sailed through Rossini’s quicksilver ensembles with assurance.

Tenor John Tessier in a blond wig was the Prince, Don Ramiro. In general he sang well though his voice is not especially luscious. His high notes came from his throat and he was unable to hold onto the one that concluded the cabaletta to “Si, ritrovarla io giuro” in Act 2. Still a credible job.

Bass Eduardo Chamma chewed up the scenery and the proximal section of the auditorium as Don Magnifico. The Argentinean bass is in the mode of Salvatore Baccaloni. He seemed to be having a good time and so did the audience. His voice is loud and agile though not especially mellifluous.

Keith Phares was Dandini, the prince’s valet who pretends to be his master. He played his part with more restraint than Chamma (less would have been impossible) and his impersonation was accordingly strong.

The staging was by Kevin Newbury. He chose to set the opera in New York City at the depth of the depression – circa 1933. While the time shift which seems to be the rule for opera today did not get in the way it didn’t add much other than saving the company some money on costumes. How come an Italian prince and baron are living in Manhattan? Otherwise he was right on the mark. His characters moved in sync with Rossini’s madcap story and his changes in lighting added to the general sense of comic mayhem that pervades the work. I was tempted to call the fashion police – Ramiro’s men wore tails and black tie.

Rossini’s comic operas are one of the summits of Western art. his genius comes from his incredible inventiveness, technical virtuosity, and sheer inspiration masked in a package that makes its contents seem inevitable and easy. After all anybody could write those tunes though no one else seemed to do so. Nobody else, not even Mozart was writing great operas (note the pleural) before his 25th birthday. If Cenerentola is not quite as mad as the Barber or L’Italiana in Algeri it’s close. Only a company at opera’s top rank can do it justice. Glimmerglass hit the target’s center.

My only complaint is that the Rs in “Questo è un nodo avvilupato” weren’t as emphatically rolled as i would have liked. Glimmerglass is not easy to get to if you don’t live in New York, but if you’re in the vicinity during the Summer it’s worth a special trip. It’s also only 8 miles from the Baseball Hall of Fame which adds a second reason to make the journey.

Saving Money on Medical Care

August 21, 2009

Here’s an intelligent article on the realities of new health care legislation  posted at a surprising sight. Well worth reading. Remember if a new program can’t reduce the ruinous cost increase of medical care it’s not worth doing.

The Health Care Cost Saving Myth

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Healthcare Cuts in British Columbia

August 18, 2009

Read this article to see what happens to government health insurance. It’s another example of less healthcare costing more resulting in even less medical care.

Drastic health cuts coming in Vancouver: B.C.

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Medical Care as a Right

August 15, 2009

If you asked a large randomly selected group of Americans whether medical care was a right many, perhaps most, would say yes. Analyze what such a right entails. If Mr Smith has a right to medical care but can’t afford to pay for it then Mr Green must. It’s a zero sum game. Smith consumes 100 medical units, Green provides it – 100 minus 100 equals zero. Green, even if he doesn’t want to, must pay or the government will confiscate his wealth or his liberty or both. Basically a “right” to medical care is a right to take away someone else’s property without his consent. You earn the money, I’ll spend it. It hides under the cloak of Social Justice. And eventually this “right” turns out to be worse than a zero sum game. Costs rise for all and service becomes scarcer.

What people have a right to is to purchase medical care (or anything else) under conditions that are the same for everyone. True rights do not sum to zero. Their exercise does not impinge on the liberty or property of someone else. For a detailed exegesis of this subject see George Reisman’s article The Real Right to Medical Care versus Socialized Medicine. Written in 1994 in response to the Clintons attempt to pass a national healthcare law the essay is still pertinent to the current administration’s attempt to enact similar legislation. Though more than 30 pages long, it’s well worth a careful read. It clearly explains why medical care is so expensive and why the government is responsible for its high cost and how a national healthcare law will result in both higher costs and less medical care, ie rationing.

Effective reform of medical care requires knowledge the public or the press usually does not possess as well as a political will that is not characteristic of most Western societies. No Western society has effectively dealt with this problem. The Swiss are often cited as having solved the problem of universal medical coverage, but they are bedeviled with run away costs as is everyone. Nevertheless, their system is worth study.

The Swiss Healthcare System (2002)