Sunday, May 17, 2015


A curious idea came into my head the other day. A concept, really, as it  furnished itself into a full blown thesis. You might ask what the thesis was about. That…

Man is meant to fly!

Looking at those creatures that take flight under their own power, the answer would be no. Man therefore was not meant to fly. That then is the original antithesis.

Yet when I look at the airplanes, man has learnt to utilize material to allow himself to fly through the air. True that! And recently the Jetmen who flew over Dubai, suggests that man is coming closer to the original hypothesis of man is meant to fly. This then is the new synthesis.

The dialectic proceeds and furthers our notion that we as humans go boldly “there” wherever “there” is because it is there. The original thesis continues to be reframed by the antithesis. The mind forces the world and brings it to its knees. Space and time are forced through the dialectic of a mind into substance and causality. And eventually the antithesis reforms the original thesis; “Man is meant to fly but with an assist!” This might change in the future, since there are antithetical arguments already in place to re-synthesize the newly reformed thesis.

The universal paradigm of giving birth to a thesis also leaves a constant trail of evocative pebbles in its wake. Not every concept takes flight after all. Each pebble a “run in with the antithetical monster,” is a constant reminder of how the world is shaped. Each pebble an outcast, lost in the whirlwind of the antithetical argument, never to realize its goal. In golf there is a truism about putting, “Not up, not in.” That is true for the discarded pebbles in the trail of a shaped reality. One such fresh pebble lies behind our last footstep, forced by the antithetical force of truth and finds itself heaped in the basket of ruined thought.

This thesis that lies bleeding, by a thousand cuts, is the Maintenance of Certification (MOC) requirement for physicians. Here the thesis propounds some fallible arguments pitched only by the conflicted souls of the organization. The originators of the MOC, ABIM/ABMS, claim there is a need for MOC and the importance of MOC is for the benefits of the patient care; public good is implied. Hidden, but recently revealed, is that there is no benefit to either the patient or the physician from MOC compliance, except only to the agency (the ABIM/ABMS), that collects millions of dollars in fees pays the officers handsomely in 7-figures and then plows the remainder into the ABIM Foundation.

The thesis suffers another deadly and paralyzing blow when it is revealed that the chief and pilot reason for this thesis to take shape in its current manifest form is to rake in money to avoid the organization from falling into the abyss of bankruptcy. Meanwhile, the money flows from the guileless physicians and the system lavishes itself with the royalties from the same distracted, confused and easily persuaded group under the guise of “do no harm.” Ah the muddied waters get muddier by the hour. The blows are many and the MOC’s outstretched limb for regulatory help might be a bit late to resurrect its image of a once beloved and dedicated organization. Indeed money has re-framed the shiny robe into a moth-eaten fabric of greed. The environment has decayed, ripe and teeming with the entozoon.

The only correlate that I can find to the MOC phenomenon is a malignant leukemic cell that thrives in its micro-environment where it is fed by supporting cast of other like-minded cells to prosper and proliferate at the detriment of the host. Sad but true. That is the Yin and Yang of life. To kill the beast or perish under its weight.

The antithetical argument to MOC seems to have found its stride. MOC was never meant to be helpful to the patients and their physicians - this much is well established. The original tenet was faulty! The antithesis is robust. Hence no synthesis is possible. A human response antidote is needed. The dialectic is fractured. The vein of fiction is ruptured and the vessel exsanguinated. There is no life to support here. The EKG is flat lined! No breath, no pulse, nothing! The thesis is dead! 

Move on!

But, “No,” say the enriched tarnished brass pining for the polish to shine, “The MOC is dead. Long live the MOC.” Apparently the new/old thesis has not been fully realized by the players yet. The old verified and validated thesis being, “CME is still king.” NBPAS (National Board of Physicians and Surgeons) seems to understand that very well and so do most 97% of the physicians (based on a SERMO survey).

“Move On!” 

Wednesday, May 13, 2015


There is an interesting play that is playing out in front of our eyes. It is quite provocative and stealthy. It is filled with all sorts of assumptions and the players are well dressed in expensive costumes. The play is being staged in every Main Street America. The players strut their stuff as the Tchaikovsky 1812 Overture plays in the background. You can spot the stagehand peering beneath the curtains looking at the audience reactions. His eyes appear and disappear through the course and simultaneously the players direct their attention to a specific segment of the audience. The undercurrent in that attention is a warning to stay quiet, be attentive and follow the discipline of proper public discourse.

Let us make some substitutions: The patients and doctors for the audience and the Bureaucrats and Authoritarians for the Players. And now imagine the Playwright standing with his bejeweled hands folded at the entrance to the stage. His unscrupulous eyes darting this way and that looking for any displeasure that the audience might register and turning into slits with pleasure as the audience claps its approval.  His Cheshire cat like smile is both radiant and visible to the pleasure of his players. Some of his actions are teasing, some tortuous, some monstrous and some evil. Like mathematics for most, his musings are irrationally caged in obscure symbols and drive his desires with help from the willing. It is in this style and the proofs rendered that the character of this maestro shows, couched in euphemisms, evoking images of empathy yet holding the glare of dogma and detriment.

Okay now to reality…

If you haven’t yet noticed, bet this will get more than a silent response: the current zeitgeist in the U.S. is to vilify the doctors. The daily headlines declare that the healthcare costs are burdening the society and account for 17.9% of the GDP. And you say to yourself, Hmm that is true! The next headline suggests that the Doctors should “Choose Wisely” in their diagnostic and therapeutic endeavors. The implication of course is that doctors don’t. The other new bandwidth that is being stretched to carry their messaging is that Medicare will now pay only for “Quality care.” Again implied therein is that patients do not get quality. And here the real kicker is how does one define quality? There are no hard or soft metrics to determine quality unless one considers ONLY the cost of rendered care. If you have not tuned into the “2012 Data Dump” that clearly showed that the doctors were direct paid $77 Billion that year from CMS expense of nearly $1 Trillion ($1,000,000,000,000.00), take into account that there are 850,000 physicians that were paid for their services, which included their overhead costs. If you have a calculator handy, that, translates to $90,588 per physician. So on the one hand the talking heads are railing over the costs and pointing fingers at the physicians and yet the reality is quite different. Isn’t it? Where is the rest of the expensed money? That’s an easy one to answer… Administrative expenses, “Hospital-facility” care, Pharmaceutical and Device costs of course! "While the AIDS Healthcare Foundation has criticized the price of Solvadi treatment—$84,000 for 12 weeks, $168,000 for 24 weeks—two Leerink Swann analysts said in a note to investors the cost was comparable to the other treatments, citing in part the $66,000, 12-week cost of Olysio, and $100,000 for an eight-week combination of Solvadi and Olysio." Don't forget, there is a price for innovation in there too...

...but none here except...make plans to take money

When some physicians start talking about Fee-For-Service (FFS) as in Concierge Medicine, the pundits descend on them like vultures calling them “greedy doctors.” These pundits continue to trawl the waters, with nuclear device carrying nets, for planktons. But don’t you think, costs can be best contained when the buyer and seller of a service are equally involved in the contract?

Perhaps, only when one sees the human affairs from a distance can one see the convention behind them… For the Rulers, their proof glides smoothly over the water as the turbulence from the webbed feet below the surface creates giant eddies trying mightily to throw the planktons into a vortex of confusion.

Then, there are the horns of this dilemma pointing south to real greed and wealth. On the south side is the new found love of having care provided at the CVS, Walgreens and Walmart retail stores. The difference is that in these locales one has to fork out their cash. No insurance payments required. There is no greed there? I am of the Austrian persuasion; win only through a better product and service, not another's destruction.  By the way In the case of Walgreen Co. (NYSE: WAG) the market cap is now $70.44 billion and is #63 in all time high market capitalized firms in the world.  Whereas for the CVS Pharmacy and now CVS Health the market capitalization is $113.4 Billion. No small change, you would agree. (NYSE: CVS) Walmart market cap should you wish to know is around $261 Billion. Good for them, but...
Most would say, well they are retailers and provide services. Umm, yes they do, but so do physicians who care for their patients and do not engage in retail sales, yet are demonized daily. Apparently these retail riches from healthcare don’t seem to bother the policy makers as they pump the dollars in their direction while heralding the new era of cheaper healthcare and simultaneously vilifying physicians. Oh by the way did I mention that the “providers” at these retail facilities are mostly non-physicians, who man their health centers and are free to write prescriptions, without a medical license that the in-house Pharmacists are glad to fill. Is there a conflict of interest here? No! …Most will say… Really? Guess there are a lot of pin-striped suits, from K street, with pockets filled with lobby money that walk the halls. CVS Health for instance, spent $14,787,646.00 in lobbying Congress in 2104. Hmm.
And if you count, 6 of the top 20 lobbyists in Congress are related to healthcare. The Quid in this is definitely for the Pro to carry to the Quo! Bring this up and their answer will be “We are making a Yeoman’s herculean effort in providing the ‘right’ kind of care that America needs.” Huh? The shades of National Health System in the United Kingdom come crawling to the mind, as the image of burning fetuses to warm the hospitals run through the mind.

Seriously, there is something out of frame. The context of reality is buried deep within Bills, Guidelines, Mandates that no one reads and everyone, lazy as they are in the government, assumes and the talking heads vocalize and the gentry’ signs on. Meanwhile patient care suffers due to denied care. Physician health suffers from early depression and high rates of suicides. Universal morals and morality decline. Substandard values take precedence. The rhetoric continues because the rulers and makers of rules have little care except for control and command. They have little worries for they will be provided with the best staffed hospitals and the most dedicated staff to care for their pinky when it gets scraped.

It is possible that the lost habit of the laity’s concentration will be replaced by the eyes of their spirit and the virtues of their needs, someday. But these are the days of unguessed configurations, unknown unknowns, uncertain futures, unglued tautologies that sneer at all of us. It might be time to hang the image in the frame correctly.

How this play will end, one can only guess. 

Meanwhile, Tchaikovsky’s symphony, with canons blazing, plays on…

Time to Wake up America.

Saturday, May 9, 2015

10 PRINCIPLES to live by.

Life is short!

1.       Live it! Make time for things that you desire to do. Read and learn from those much smarter than you. Paint what strikes your inner fancy. Write the words that have wanted to come out. Tell a story. Plant a flower. Create an industry. Channel your inner child. Look at things differently. Change your perspective. Play a musical instrument. Listen to music. Close your eyes and dream. Work hard. Be Productive. Reach for the moon and the stars. Above all, Enjoy your Family and Friends!

2.       Smile! Lose the frown lines. Develop the crow feet. Laugh often over something or nothing at all. Find contentment within yourself. Express yourself. Forgive, but do not forget. Learn from your mistakes. Cultivate human interaction. Touch a shoulder. Shake a hand. Look into eyes. Show those dimples. Surround yourself with friends. Enjoy another’s company.

3.       Keep Healthy! Eat light. Keep a little hunger. Do not satiate. Exercise. Walk. Run. Ride a bicycle. Ski. Golf. Swim. Do not Smoke. Avoid alcohol. Avoid the “Take a Pill” culture. Spend time outdoors. Smell and feel the fresh air. Create a new path. Follow a trail. Choose. Occasionally fast for better immunity.

4.       Trust! Always verify. Do not fall in love with words. See the person. Ask questions. Analyze answers. Think and rethink. Look at deeds. Listen to their personal character descriptions. Find the truth in their souls. Match their words to their actions.Validate the trust through verification…Always.

5.       Critically think! Listen. Analyze. Use your knowledge. Merge dimensions. Do not rationalize. Do not give credence without objectivity. Understand the motive. Understand your bias. Reason.

6.       Find the Evidence! From C/O > HG > PS₁ > EE₁ > PS₂ > EE₂ > RE > V
a.       C/O        Concept/ Observation
b.      HG          Hypothesis Generation
c.       PS₁          Problem Solving (initial)
d.      EE₁          Experimental Evidence (initial)
e.      PS₂         Problem Solving (subsequent)
f.        EE₂          Experimental Evidence (subsequent)
g.       RE           Experiment Repeat-ability
h.      V             Validation.

7.       Beware of Statistics! Use numbers. Careful with percentages. Be wary of contrived graphs. Be wary of Confidence Intervals, Hazard Ratios, p-values, Regression analyses, Logit. Contrived data will cloud intuition. Be wary of small number statistics. Be wary of the hyperbole. Do your own simple math. Do your own analysis. Use your personal experience to interpret. Use simple Logic.

8.       Be wary of Words! Language is for expression and understanding. Be wary of hyperbole and difficult words. Use simple words. Use context. Do not complicate. Do not use complexity. Explain with concision.

9.       If it is too good to be true? Then it is! Nothing is for Free. Someone always pays. Carry your own weight. Do not be obligated. Do not be dependent. Do not abrogate your responsibility. Do not be a ward. Do not “take it.” Do not accept a wrong.

1.   Morality! Tell the truth-you don"t have to make up stories (lies) to tell it. Be self-deprecating. Be kind. Be thoughtful. Do not laugh at another’s expense. Be considerate
. Put yourself in other’s shoes. Weather the storms do not broadcast them. Be humble. Do not impose upon others.

That ancient silent oak of Reason stands tall overseeing the valley of flowers that bloom and decay with time.

Tuesday, May 5, 2015


…and the value of nothing” – Oscar Wilde

Rip Van Winkle just woke up. Gone were the bucolic vistas of yesteryear. There are skyscraping glass enclosed buildings that obscure the horizon. Gone were the quiet, empty streets replaced with cars of all shapes and sizes humming through above the speed limits. Gone were the bakery merchants chatting with community friends outside their businesses, now they hide behind steel bars that protect the window panes and their lives from the street demonstrations.

Things have changed, Rip.

Where is the value in living, Rip wonders?

Value is an easily defined term in inanimate products and has at its core embedded within quality. And equally quality is an easily definable term in inanimate products. When quality is reduced, the value to the consumer is reduced proportionally; a 1:1 ratio exists between the two. So now we add a new term in our thought experiment: consumer. One can safely say then that the “value” to the consumer is based on the “quality, function and reliability” of the product purchased.

What happens when the producer cheapens the quality by using substandard material? The consumer initially gets duped and then fires back by voicing his or her opinion and reversing loyalty. The loss is felt by the producer whose fortunes decline from loss of sales.

The “planned obsolescence” by American Automakers forcing the consumers to buy new cars every five or so years hurt Detroit in the long run. The city is in ruins from the excesses and demands of the past. The Japanese quality emerged as the new norm overtaking the American auto paradigm. The time arrow flew and subsequently some automakers calculated risk losses from poor engineering vs. the price tag of a mass recall and allowed for the potential unmitigated risk to flow straight to the consumer, leading to eventual bad press, loss of confidence and consumer base contraction, again leading to trust-collapse.

Sometime the advancement in engineering and new value predates the social culture and companies have been known to falter for not realizing those dynamics. The classic example is Apple Computer which brought forth the Lisa computer that failed, a Newton that failed sending the company into a free fall. The latter was resurrected as an iPad and Apple is on top once again with a $700 Billion market cap. Here the product was never in question, just the timing and its value to an uninitiated customer..
So value is in the eye of the consuming beholder!

Consider this, if you paid for an orange and got a lemon. What would your reaction be? You would want your money back, Right? As it should be! Now let us look at it another way. If you paid for an orange and got an orange but decided you wanted a lemon then the only way to get your money back would be to either own up to your fault or if you were lacking in some basic morals, turn against the seller.

Congratulations Rip, you have arrived on the modern landscape! It is the year 2015 and everything has a price on it!
Consumers buy clothes, wear them to parties with the price tags hidden inside and then return them back for a full refund to the seller. Is this right? Depending on how many you have returned, most would say categorically it is wrong. Yet returns in businesses are a fact of life and are computed in their income statements and balance sheets. Everyone calls it the “Cost of doing business.” But what is the cost to the psyche of such a society, whose fabric gets ripped just a little more? No one knows, because these behaviors remain hidden under the pretext of consumer sentiments and other such politically correct niceties, espoused by the politics and the family culture at home.

The measure however does rear its ugly head in the form, of demands for free this and that. Entitlements are a growing scourge of the evolved modern human element and continue to eat away at the national wealth of the State.

Just like business and mostly because of business-minded administrators that have infiltrated medicine, there is a call for value in medical care. So the question is ripe for the asking; what constitutes value in medicine? You might say “access,” or “cure from an ailment” or “acquiescing to the demand of the patient for antibiotics or pain killers” or even “not having any future illnesses.”
These are all very formidable hurdles in reality. 

“Access” to care is the easiest and has been solved for decades in the United States. No person was denied healthcare in the United States if he or she showed up to an Emergency Department with an ailment. This has nothing to do with “Insurance coverage” policies now in vogue.

The second issue is more difficult. Curing a disease is based on the nature of the disease. If it is a bacterial illness that is amenable to an antibiotic, well then yes. But if it is a late stage cancer then the impossibility remains. So if you as a physician are unable to cure a person of his or her cancer, are you then not providing “value” to the patient? Are you therefore a bad physician? Similarly treating type II diabetes is largely a function on following directions of diet, exercise and medicine to control the blood sugar. You as a physician might spin all the wheels with education and medicines but if the patient is non-compliant, eats donuts all day and drinks sugary drinks all night, how can that bring in the hallowed outcomes? Where is the value in that?

The third issue of acquiescence to patient demands is a human-human barter deal in today’s world. If you as a physician do not give in to the demands of prescribing an antibiotic for a viral syndrome to appease the patient’s sense of “getting something done for the cold” then you are berated in the satisfaction scores equally if you don’t prescribe the pain-killers to those who desire them but shouldn’t have them. Since the consumer, here the patient, is in command and you the physician, the medical care giver, are completely under the consumer’s will to bend and shake till you agree to those demands, the social media reckoning is upon us for good or worse. Is this the “patient-centric” care? 

The fourth issue of prevention is being forced onto the physician. Not preventing a “preventable illness” leads to bad outcomes and becomes a direct result of poor patient care. The Readmission policy presently in vogue that denies reimbursement to hospitals for patient readmission for similar illness or infection is a case in point. Poor immunity is a gateway for multiple infections. A person in poor health has poor immunity; hence the re-admissions unfortunately are a way of life, but not to the experts in the ivory towers. Do these policies have real metrics in place? If not then it is just a means to control costs and deny appropriate payments for services rendered. In the business world one can litigate. In the medical world, one walks with the tail between their legs. And all the while the experts pushing value based payments state, “Moving to Value Based Payment along the timelines [suggested by the state] while incredibly ambitious is aspirational,” said Sean Doolan, chair of Hinnman Straub's government relations department. Just read the two words, “ambitious” and “aspirational.” My question is for whom are these words intended? One should wonder, is it not also the responsibility of the patient to exercise self-care? Or is the patient so infantilized that he or she does not know that smoking, eating indiscriminately, obesity sedentary lifestyle and drinking in excess will lead to ill health? Must doctors now know and divulge personal information related to their household finances and gun ownership to the insurer? The grim monologue from the insurers seems to suggest yes they must.

Speaking of the Value everyone is yammering about, here is what  Stephen Berger, chairman and founder of Odyssey Investment Partners, L.L.C., a private equity firm, and chairman of the New York State Commission on Health Care Facilities in the 21st Century had to say, “I don't know where 'there' is. And I think there is not one 'there.' There is a lot of 'theres,' and I'm concerned that a great deal of what we are counting on depends upon being able to have some more clear discussable, understandable definitions of things like quality.” He went on to say, “I see no evidence that that will produce the kinds of dollars we need to support the safety-net network and the delivery of care to all the people we want to deliver it to at a higher level of quality,” he said. “That, at the moment, is more an issue of belief and hope than something I can see analytically.” Oh, I can see clearly now that the rain has gone… Although Mr. Berger’s vision remained clouded a bit too, "We have to understand how much chaos we are going to be creating to get to some place better.”

Meanwhile the N.Y. state Medicaid director Jason Helgerson said, "That is a great start," Helgerson told Capital in an email. "We have heard from a number of providers who want to do even more."  Who, pray tell are these providers? He went on to say, The Value Based Roadmap, which outlines how this transformation will occur, will push, Helgerson said, and "Medicaid will focus mostly on carrots but we will use sticks if necessary." Does anyone feel the heat here?

But let that not perturb you because another believer states,  “Hard to say [you're] not for 'value-based payments'—it's like motherhood and apple pie,” said Valerie Grey, executive vice president of policy for Healthcare Association of New York State. The overarching question then is, Who is the Consumer...the Insurer, Bureaucrat-Administrator or the patient?

Oh dear Rip, sorry you woke up so soon and not sooner.

You see when the price of everything is known, the value of everything suffers. Cutting costs leads to cutting corners, leads to denials of care, leads to a many-headed beast that devours all in its wake or like Medusa's head that blinds one to reality.

So our minds are corrupted and we are blinded to...

Sunday, April 26, 2015

TIME VALUE of MONEY in Biz and Medicine

You know how you want something so bad that you can taste it? It was one of those wants. We all have them from time to time. Things that matter little in the scheme of things, yet at the appointed hour they burst open this bouquet of desire. I thought as I stood in line for the future value of the shiny product. Hmm… it could do a lot of things that would make life easier for me. Easier, did I say? Maybe a bit more complicated is the correct phrase. Eventually, ending up third in line for the shiny object while waiting, you know that ethereally nebulous thing that pricks a bubble in your conscience, pricked mine and I proceeded to exit the line to the gaping mouths of the patrons behind me who had gotten to know one another over the past few hours. Yup, I left. And here is why…
Before I go there, here is a question for you. Is buying a used car better in time of value, all things being equal in quality, better for you? The answer will surprise you. Ask any sane person and he will tell you that the depreciated value of a product is cheaper than buying it brand spanking new. Less money same bang for the buck – four wheels, an engine and a personally desired chassis is the same as under the lights of the showroom. This is a form of time value of money.

Ok, now keep that in your mind as I go down this rabbit hole. And there are plenty of finance-majored caterpillars asking, “Who are you?”

There is something called Time Value of Money or TVM. You might have heard of it. It turns out TVM is the biggest single business issue that occupies a financier, financial analyst, manager, a CEO and anyone else involved in the complex world of commerce.

Tomorrow’s dollar will buy just a bit less than today’s. It so happens that this rude thing is called inflation, or “less buying power.” This little culprit has robbed us of our wealth in many different ways. Most people have never even thought much less dreamt about them. Look up the difference between “nominal” and “real.” Go ahead look it up. This can wait.

Let us say we have $100 in our pocket and the current interest rate is 5% then the simple equation to understand the Future Value (FV) as it relates to Present Value (PV) of that $100 is:
FV = PV (1 + r) and (r = interest rate) = 100(1+ 0.05) = $105 The Future value rises doesn’t it…also meaning that what cost $100 now costs $105. Or the future buying power of that $1 is now $0.95. Oh dear!

So if we want to know the FV in n years we plug in the formula: FV = PV (1 + r)^n where “n” represents the number of years = 100 (1 + 0.05) ^5 =$127.62 which is more than the simple interest rate of 5% yielding $125 (or $105+$105+$105+$105+$105=125) that is if the interest was added only to the initial principle and not on the accrued amount. Simple isn’t it? But look here, here is another nifty thing about this formula; If you want to see what today’s value is for tomorrow’s money than a simple algebraic magic gives us:

PV = FV (1/1 + r) ^n (n being the number of years) You see, nothing to it. Got it?

Now let us look at how big people exploit this little formula to their advantage…

Heard of the Revenue Cycle? That is if you sell a product, you send an invoice and the buyer then has 30, 60 or 90 days to pay off the bill. Here is the subtle catch, the buyer can use that money (designated to the seller) for other things and since time is advancing, the value of the amount owed is also dwindling in real terms of purchasing power. Huh? You say, but it is not even a year yet. How can that be?

Elementary, there is another beauteous term called “Compounding Interest.”  If the buyer’s money is compounding interest on a daily rate his value in 90 days based on compounding interest will be a bit more than if he pays it off immediately. So he has taken advantage of the Future Value of today’s money. Or in simplistic terms he is paying with dollars that have less buying power. Smart, eh? Oh, by the way the formula of the continuously compounding rate (and that my friend is the real golden goose) is slightly modified. I call it “Pert. ”

P = Principal amount (Initial Investment)
r = Annual Interest Rate ( as a decimal)
t = Number in years
A = Amount after time t

FV = P * (e)^rt  ~here “e” is the natural log (2.7182818) and “r” is interest rate and “t” is time in years. So you see if the bank for instance charges you a continuously compounding rate but pays you interest on your savings at an annual compounding rate, guess who wins? = 100 * (2.71828) ^0.05*5 = $128.40 vs $127.62. You won’t scoff at that number if you figure those transactions in the billions!
Let us see how the Medical Revenue Cycle permits such shenanigans. If you want to know a little more about Medical Revenue Cycles it is here.

A doctor sees the patient who needs a surgical procedure. After the operation the doctor sends a bill to the insurance company. You might as well know this little known caveat up front that almost 11-18% of the bills are automatically denied, some for not dotting the (i)s and others for not crossing the (t)s and still others because they can, by requiring more justification needed for the surgery. It’s the need based on “patient’s welfare” excuse as if they the clerks know better than the surgeon. They DON’T (my emphasis)! So the delay continues and finally the payments are made sometime 6 -12 weeks later for amounts much lower than what was billed. I know you are clamoring to know a surgeon’s bill say for a cholecystectomy. Current Medicare and other insurer payments range from $367-580. That is it and within that payment is bundled a 90 day post-operative free included global follow-up (that means the doctor is responsible for all care pertaining to the surgery)! Guess what, but I guess by now you have already figured out the opportunity cost (the cost of using that money for other purposes by the insurer or keeping it in the investment vehicle of their choice where it would yield a continuously compounding rate will deliver a higher amount than what is paid out to the doctor both by delay (TVM) and by denying (TVM) and by decreasing the reimbursement actually due. A win-win for the good ol’ insurer dudes!

These dollar amounts are miniscule, you might say, “What’s the clamor all about?” Now simply multiply the 850,000 physicians overseeing the care of 320,000,000 people in the United States on a daily basis and the numbers get huge. I mean astronomically huge!  Hence, the delay tactics by the insurers to enrich themselves with the ballooning Future Value is more than a delay tactic, It is a handsome reward! And that is how the AVERAGE Healthcare CEO salary is now tipping at $11.4 million apiece. These CEOs are , most of them anyway, if anything, not dummies!

You might see businesses sending you invoices that say if you pay in 15 days you can get a 2% discount ($1 in hand is better than $2 in the future) or after 30 days they charge 2% and 5% after 60 days. They have it calculated to a tee. They ain’t losing money honey! Based on receiving their money quickly, they can put that money to investment which can have a better rate of return than the 2% they give you. And you thought CEOs just had wild parties. They do but after they finish counting their loot.

Hopefully you have a better understanding on games business people play.

ABIM Retreat Resort

I was going to end there but this juicy script of the ABIM redirected my attention.
Let us start with a company that makes a widget. The widget company obviously has costs to make the widget, right? So the money from the sale (called Revenue) of the widget  goes to pay off the expenses related to the widget and what is left, is called in business parlance “Gross Margin.” If operational costs are subtracted from that then it is called EBIT (Earnings before Interest (on loans) and Taxes.  So in ABIM’s case they claim 200,000 physicians are certified and roughly 12,000-14,000 physicians take their certification and recertifying examination annually (based on ABIM website) and 80,504 certified physicians are taking part in MOC every 2 years. Given what I have paid in the past, I would put the cost at somewhere around an average of $2000 ($1385-Internal Medicine-$2830 Sub Specialty- from ABIM website). If you multiply the number of physicians to the cost of the exam, that is big money. Add $500 per MOC event to that and it takes on a whole new meaning about BIG money! And that is all Cash receipts up front. Their expenses, they claim, are the cost of making up questions and organizing a Gestapo-style examination where a physician is “searched” before entry and afforded other indignities. And if you cancel before the exam date you forfeit 30-45% of the fee.  Huh? I guess they plan to limit cash flow reduction issues – read on. They claim creating the test questions and organization of these examinations costs a lot. And self-promotional articles as “Evidence” for the recertification and MOC needs cost money. They might have to pay to blind the co-authors about Conflicts of Interest, maybe? Okay, so deduct maybe, what, 20% on the high side? The left over is their Gross Margin. And where the money goes in this non-profit 501 (c) 3 organization is to pay the executive compensation. Getting back to the TVM, the money they take from physicians is at least 3 months before the certifying examination and at the beginning of each segment of the MOC. The computerized certifying examination results are reported 3 months later – minimal effort on the human element just tell the computer what number of doctors should fail so that they can come back for another examination and pay for it again. The excess dollars in the kitty after the lavish $1 million salaries are disbursed, going towards the multimillion dollar condo in Philadelphia and the Mercedes limousine under the auspices of the ABIM Foundation (a valued partner for slush funds) and to cater to their extremely secretive meetings about how to write more examination questions.

Photo from Newsweek Article

Kurt Eichenwald exposed the Accrual-based accounting thatABIM is doing. It appears that their net asset value which is based on the Present Value of the discounted Future Cash Flows is propped up to a robust number while simultaneously bleeding out the cash for Executive Compensations and other expensive resort “Retreats.” They are hoping that the Future CashFlows will continue to grow as a consequence of “undertaking this herculean effort for the public good.” What they might not have considered was the fact-finding- storm that led to a physician backlash over MOC and is going to leak some future cash flow. One would think that their estimates of the Present Value of their discounted future cash flows will drop significantly in the very near future. You think? The future of this new Present Value is going to be interesting to behold as less comes in to pay those handsome salaries. Maybe put the Philly condo up for sale (for saving face) and go on a diet at the retreats? Possibly?  Just maybe? Maybe? Uh? (That sentence reminds me of MacFarlane’s Stewie).

It is time to consider what will be from what is and likewise what is from what will be. It is also time for physicians to consider why pay into a corrupted system.  That money for MOC and recertifying examination has opportunity costs for better investments than going through the rigors of an examination like MOC/ABIM recertification conducted in a Gulag environment and holds no beneficial, educational, value to a physician or to the patient, unless you are a masochist - there I said it! That money is spent better elsewhere, in your practice, taking care of your patient!
There you have it, a peek from the business end of the stick and the derriere of the physicians; a story about the trials and tribulations of the many who serve a few (masters).

Oh, by the way, I got that shiny object three months later for half the price…

Wednesday, April 22, 2015


Strange how time travels
Away from the moment
Leaving behind memories
Rich and poor.

Like a broken cup
Shattered by a fall
Accidentally moved
Off the table’s edge.
Now shards surround;
Pieces. If all placed
Neatly together would
Make the cup, But no.

Like the writing hand
Having writ moves on
The delicate impertinent ink
Marring the parchment
Filling the shallow valleys
And riding the rough ridges
Forever in the life
Of that pulp, ingrained
With memories on its surface
Dissolve to the first rain drop.

Memories too of childhood
Ghostly beings in ether's dance
Moving further and further
Away from then
Stretching back into oblivion.

Echoes of tortured minds
Leaning this way and that
Filling the space
With colors and black.
You cannot pluck the petal
From the rose, yet still
Smell the sweet smell
And only imagine
What was,
When it was.

The minute hand
Pulls the hour hand
Only one way.

Ah time your arrow
Has, but one direction
Yet you curve under gravity
And might bend to meet the edges
To make travel through moments
Possible. Even if for a fraction
Of a second. Like the crackle
Of lightening expanding
Space and registering time
With the sound of fury
And like that moment
Gone. Lost to oblivion
Within ghostly memories
Haunted by time.

Friday, April 17, 2015


“It’s a 4.5 Liter engine with a 325 pound-foot torque, at 7400 rpm and a 3.81 displacement puts this car ahead of any other…”and attention deficit took over. The backdrop of a car showroom and the voice of a salesman is sweet harmony to imagination.

Yes, I wondered, we can certainly measure the volumetrics of the car engine in precise detail. We can measure most anything on the planet with exquisite precision.

From ancient time when Eratosthenes was able to measure the circumference of the earth to within a few stadia (plural for stadium), man has been on this quest to quantify then qualify through measurement anything that exists on earth, from ether to the rock of Gibraltar. Time has allowed us to gather more and more measuring tools. From ancient times when the distance between the earth and the sun, aptly named Astronomical Unit = approximately 93 million miles, took many failures of measurement from Aristarchus to Kepler, finally it was Christiaan Huygens who determined that it was equal to 24,000 earth radii, man’s quest to measure never wavered. 

We came to find out that the Cesium radiation period determines that "The second is the duration of 9,192,631,770 periods of the radiation corresponding to the transition between the two hyperfine levels of the ground state of the caesium-133 atom." And using this information, humans devised the Atomic clock. Time linearity was harnessed. Progress! 
We can measure the very large galaxies millions of light years away through cosmological red shifts to the miniscule cellular interiors and thence to the absurdly minute small atoms within, with tunneling microscopes. We can smash protons and electrons together to reveal the approximate behavior of the “big bang.” We can approximate the energy of the Higgs boson (the God Particle) at 125 GeV based on mathematical calculations after the smash. And Einstein who could imagine the Spooky entanglements mathematically decades ago was experimentally proven correct!

Image of Saturn surface from the Voyager

Satellites hover and tell us our positions within inches and we send a spacecraft hurtling past into into the interstellar space, named "Voyager." Human ingenuity is Amazing! 

When it comes to humans, measuring humans, we have been even more curious; the developing fetus on a 3-dimensional sonogram lays out features of the baby vividly and from birth starting with the APGAR score to the baby’s height and weight to blood pressure and red cell volume, from intraocular pressure to intra-arterial pressure, from the speed of electrical impulse generation in the brain and its impact on the synapse to the beat generation from the Purkinjee fibers to the myocardial cell contraction, almost everything is measured and quantified. We measure salts, hormones, enzymes and other sediments including circulating tumor cells in the blood. We tie behavior to psycho-neuro-chemicals in the brain. We measure the change in ratios of various elements from health to disease. We check and check and recheck to stay healthy. We graph circadian rhythms and everything from circulation in clogged arteries to emotional volatility, to cancer and throw them all in the stress-me basket. Indeed we have arrived at our purgatory! 
Today, however we have a seismic shift in our thinking as we find a new pleasure in measuring the genes and their mutations that cause loss or gain of genetic function. Some of us have come to realize that genes are motivated by nature primarily and through nurture secondarily in equal measure. We have learnt that miRNAs and methylation processes constantly modulate gene function via external pressures. Oh yes, we can measure the human milieu quite well. Essentially down to what makes us tick. We can outline functional paths within our brain, the moment life begins and even have the audacity for perpetuating a lack of responsibility, to subsume our behavior to the function of a gene code. We can map the brain yet remain searching for the elusive mind, just like we have the body but always are on the look out for the soul? Ah yes, we are the Lewis and Clark muddling through the forests, not figuratively but metaphorically, of digital 1s and 0s and calling it the new dawn!

And the new sheriff in town wants to measure something else. His particular penchant is trying to measure a different metric; the human emotion. He seems to think if we can measure the happiness and quality of that happiness or sadness then we would have measure of performance just like the 10 point numerical scale of pain. Yet what he fails to recognize is the vice within the 10-point pain scale. Is my 5 point pain as a stoic equal to your 5-point volatile emotional pain? If the answer is yes then I guess the metric is valid. If the answer is no then we better go barking up a different tree. What do you think? Where is the threshold? Some qualifiers are definitely needed, “oh but that would make it so difficult!” Whether we use the numerical scale or the Wong-Baker FACES pain scale the answer would be the same. The thinking goes…if we can tie emotions to a scale and the scale to value then we can tie cost to value and voila, problem of costs in healthcare will be solved. The bureaucrats crackle their knuckles as their salivary drools thicken. Does the smile mean happiness and does a frown mean anger, always?

Alas even Kant at his most vulnerable in his hardened shell of the categorical imperatives would have shied away from such acts of calumny. As I understand Kant’s deontological ethical philosophy, he would believe that an action should be judged by its implications, “Act only according to that maxim which you can at the same time will as universal law.” Would such actions become the universal law?  But hey, forget those philosophical fire-hoses of discretion. This is the brave new world, where anything goes just to “feel good,” or be in the act of “thinking of doing good,” or be involved in the “public good” business.  There is no withholding any assistance from the passions but allowing them to promulgate thoughts and those thoughts into actions that hold hostage an entire society. The hypothetical imperatives have now become the categorical imperatives.

The world has changed stupid, get with the program!
Similarly quality of a human state is a difficult measure. The moment to moment emotional energies that crackle through the brain change the internal and external emotions of the human being. I feel good and the thought of a lost friend kills that feeling. I feel sad and the thought of winning a prize elates me. Measuring such volatility and using that as the parameter of success is tantamount to, perhaps foolhardiness? Must we then ask for everything that is going on in the brain and the mindfulness on a momentary basis? Mustn't we? Or can we compartmentalize, as the experts do writing lengthy treatises?
If value was being judged by a single individual who also happens to have her emotional cake to bake in the measurement, well then all bets should be off. Wouldn't you agree? The multivariate of the "measured" and the "measurer" would be in play and confound answers on a large scale. Yet to a mind indulged with the liquor of metrics none of that matters. Reality is that the "measurer" would have to have their emotive moment to moment state of being, assessed and recorded in parallel too! Maybe the human being is a mathematical model, with limbs tied to the Golden Ratio n’ all and as such can and should be measured for functional efficiency that could be the surrogate to a form of well being? If that's possible?

Speaking of functional efficiency, productivity is one measure that can be allocated to the value of good health, but therein lie the specter of employment, entitlement, vacation time and desire. “I am well,” suddenly takes on a different meaning in different circumstance as does “I am not feeling well.” Speaking from the dais and pontificating the virtues of life before 75 years of age is all well and good, but don’t these high minded priests and priestesses remember what “Said a blade of grass?”  Functional efficiency  is now indeed rooted in a foul jar of expertise!
So what do we do?
How do we measure a human being’s quality? Or for that matter, how do we measure a physician’s work in helping his/her fellow man/woman survive through illness and gain that quality? Oh that one is easy. If the illness is appendicitis, an uncomplicated appendectomy is the answer, unless of course an anomalous artery is nearby or a co-morbid state decides to exert its influence. If it is pneumonia then an antibiotic is mostly curative, unless you develop an allergy to the antibiotic. After all we are all human beings made to order under precise sets of rules and creative force. Aren't we? But what if it is an incurable chronic ailment like diabetes or arthritis or cancer? Is cure the measure? If it is, the best professors in the ivory towers would fail the test. Wouldn't they? They would never admit it though. But let’s just keep that to ourselves.
Scoring value is a difficult thing. A patient recovering from an illness dealt with the news of hospital stay costs would necessarily be disheartened and score low on the “Happy Quality Scale.” Meanwhile a terminally ill patient might have found peace in his or her wretched state and score high. How would that impact the score? A non-compliant patient due to medication cost or lack of access would not be too happy with the world. A compliant patient with dwindling resources would equally not give a smile willingly.
So we arrive at this conundrum of lunacy created by a confederacy of some "very intelligent thinkers” that everything from spit to pee and blood to tears is measurable, hence so should the real quality of emotion. And measuring emotions has value and value is therefore quality and quality can be paid in dollars.

The "turfing" war is about to begin in earnest among well-intentioned physicians!
Therefore if we weight the sampling errors appropriately and place alphas and betas in the equations we would arrive at a formula that will guide the value of therapy as benefit to the patient. Further derivation from that would justify the appropriate reimbursement to the hapless physician. Are there Avogadro's constant or Plank's constants for human beings that can be fitted into our equation to gain that subtle but elusive inference? Not yet! Although the reactive heuristic makes us act as if we do, by latching on to the Confidence Coefficient of 1.96 and with that and the statistical jargon we attempt to prove our hypotheses time and time again, forgetting what the Nobel Laureate Philip Anderson said, "Many good scientist instinctively distrust a measurement which is always on the ragged edge of "statistical significance" and have learned to be very skeptical of marginal statistics."
The new HR-2 MACRA Bill soon to be signed into law, quantifies such actions and emotions- should anyone care to understand, will do the following: Derive risk adjustment calculations, Quality and Outcome metrics, case management, resource use monitoring, interoperability of the EHRs, establish data registries, develop practice assessment checklists, determine the operability of the physician NPIs and their ability to prescribe…and on and on and on, you get the message! Happy navigating the tall grass…
We thus arrive at Kafka's "Nothing alive can be calculated!"

“So the monthly lease on that would be…” I was all ears!