## Wednesday, April 23, 2014

### CHANCE ..is Real

“If it don’t fit, you still must convict!” no I don't think it was this way...
What a wonderful thing chance is! Look around you and you will see a myriad of things that are a matter of nature’s play with chance. Like that beautiful pink rose that shares its DNA between the red and the white roses in the bush, only massaged by the right iRNA. And the African child living near the Sahara that looks up at you with the most beautiful blue eyes that are spellbinding and you wonder; how?
Or the girl that made it to the National Geographic front page, she too had those enchanting eyes that captured the imagination of the world for decades.
Or in the wider circle of humans let us look at chance a little differently; In 1896 Henri Bacquerel found that the uranium enriched crystal caused a “fogging” on the photographic plate in an enclosed bag (without sunlight) revealing to him the nature of radioactive decay, Watson and Crick walking into the lecture hall to listen to Rosalind Franklin about X-Ray Crystallography gave them the intuition of the DNA helix,
Or on September 3, 1928 when Alexander Fleming returned to find a fungus on his dirty dishes that had killed off all staphylococcus bacteria, giving birth to Penicillin, In 1964 Arno Penzias and Robert Wilson discovered that the constant hum from their radio telescope was not bird poop on the radio-telescope but the murmurings of the Big Bang; Or in 1967 Percy Spencer walked in front of a vacuum tube magnetron that made microwaves and found that the chocolate bar in his pocket had melted; And with John Pemberton a pharmacist trying to create a remedy for headache accidentally mixed the cocoa leaf and cocoa nut with carbonated water and lo and behold Cocoa Cola was born. So you see serendipity or chance plays a huge role in the life and times of the human discovery and innovation. Here is a real doozy of a recent serendipitous thought from Franz-Josef Ulm about the physics of urban sprawl . From aerodynamics to medical discoveries to drug development to the tallest skyscraper, the ideas take force from the seedlings of chance that sparks the imagination. The likes of Stephen Hawkings and Albert Einstein have as so many others, had their wanderlust intrigued by that moment of chance inspiring them to the heights, unfathomable by most humans.

The collaborative spirit of chance and insight has advanced life from time immemorial. From the birth of the flint arrowhead to hunt and gather to the quantum bits of digital float in the ether, there is a measure of eureka moment of suddenness that supplants all other things.

Chance is chancy. If you have flipped a coin for more than 10 or a 100 or even (if you had time) a 1000, you would find that there is a longest run of heads or tails mixed into the outcomes.
P(nm)=j=1n/m(1)j+1(p+(njm+1j)(1p))(njmj1)pjm(1p)j1
De Moivre in 1738 calculated the answer to the coin toss experiment and the number of heads as an outcome to the number of tosses. Within that is buried the notion of a run on chance, like the winnings from a Roulette table, or a game of cards or a run on picking the right stocks for a good return on Wall Street. In all this there is no expertise (experts will vociferously argue that there is), but a game of chance that pervades underneath. So within that spectrum of pure chance all probability functions assume a degree of randomness inside the the mathematical equation to arrive at a predictive value. The prediction is just that, a prediction and not a gospel. I have to remind myself of that every day. So should you.

Time has changed though. The latitude of thought now seems to want a different approach in human affairs. Armed with the forced-silliness of force-merger between mathematics and probability mechanics, some have embarked on a rueful journey to use chance in a distorted way. They are force-hiding needles in the haystack that their mechanistic algorithms can find. And then they exclaim “Eureka!”
But these “Eureka(s)” have different modes. These are algorithmic nuances designed to find the deliberately “hidden” chance episode of intent and declare victory through the art of the probable.

You must have heard of the Hazard Ratio that is a time-event analysis and from there at the end the difference between two arms determines the Relative Risk. That is all well and good, it is simple, direct and to the point, no shenanigans here, but when one starts trying to “Fit” the results into the Gaussian Curve for a prediction and then claim that all “norms” should perform within the bounds of the curve, there lies the conundrum of fiat, force and mandate. Simply stated these experts utilize O.J. Simpson attorney’s statement in reverse, “If it don’t fit, you still must convict!”

The word Outliers is a common word in probability and it identifies a subset that does not “Fit” into the perfect Bell Curve. The Bell Curve is designed to capture (two standard deviations from the mean) mostly the 95% of the targeted variables/human subjects. So according to the expert  “probability masters” the 5% who are the outliers are somehow errant in their ways. And this interpretation of chance is now driving these “outliers” into the fold of bad actors, evil-doers or even “killers!” The zeitgeist that pervades wants to force fit all into the commonality of predetermined thought. All thought and action must be comported to the diktat of this time!

By very rare events they mean less than 5% chance of them happening

Maybe someone who is not vested so heavily in the conjured outcomes might find it necessary to consider the magical sprinkles of chance and expose the rottenness that invades reason. The dodgy air of opportunism and profiteering seems to take the lead in today’s pseudo-scholars whose eyes are always on “how will it help my resume/career/advancement/bonus.

Nature continues it’s forwardly drive in the human destiny to evolve the structure to face the environs through Transposons jumping to modify our DNA code. She is a good teacher. We should learn about chance from her. And even though there will be many Archimedes jump out of the bathtub moments in the future, the dark matter of thought unfortunately has found a relic in this crucible of probability and continues to exploit it to its own end!

Ah Chance, why do you so torture us now within our limited self-serving viewpoints even though we are so “refined” in our thinking and wholesome in our being?

I can see a better science out there, unmolested, unvarnished and real! I have seen it in the history books. I have seen it in it's tried, tested, validated and verified form. It is there for the asking. It is there for the understanding.

IT IS THERE!

## Friday, April 18, 2014

### Commoditization of MEDICINE

It dawned upon me, the importance of a name. Unlike Shakespeare who deemed that a “Rose by any other name would smell as sweet,” I beg to differ, not about the smell but about our perception of the rose, if we called it, say a “skunk.”
There is more to a name than meets the eye.

Doctors have long been called “doctors” because they were in Latin considered Church fathers, educators, advisers and scholars. Hmm sounds like a lot of hats to wear, doesn't it? But think about that for a while and you will find truth in it. Doctors do, advise, they are learned in the arts and science of medicine, they educate against unhealthy behaviors. Similarly the word “Physician” in Latin holds court as the natural science and art of healing, something more in line with being a doctor.

But recently the word in the politically correct world does not smell as sweet; it is “Provider!” Now why would anyone shy away from the word, doctor or physician that has been in use since the days of Hippocrates and Osler to this one coined by the elite? There must be something to it. For what’s in a name, you might ask?  Ah! But there is power in it. It (the name “doctor”) has long been immortalized in prose and poetry, in annals and tomes, in sickness and in health, in life and death and in any form of ritual or ceremony. Oh yes the word “doctor” has a significance that none other have. It is not the station or the pulpit but the knowledge and the critical thinking that goes with the art and science of medicine. That art, my dear friends cannot be replicated in the IBM Watson or the Star Trek Holographic guiding image of the future.

So then, why did the elite change the term doctor into provider?

To answer that question, we have to look at the word, “Commodity.” Commodity is a marketable item. It satisfies the “needs” and the “wants,” or “demands” if you will, of the populace. Since the commoditized product is not differentiated enough, the demand is great and the margins (or profits) are low. Hence the commodities that people cannot do without are bandied about in the market in greater supply to meet the demands. These commodities can be “hard” (mined) or “soft” (grown).  Examples of commodities include staples such as milk, wheat, corn, soy beans etc. You get the message.

Why does something become a commodity? Well, if the product differentiation is lost in either its function or functionality and is easily available in the marketplace, that product has been commoditized.  Lo and behold, the word Commodity was first brought into the lexicon by none other than the French, who have a penchant for socialistic ideals.

To commoditize, one has to mass produce the product or has to reduce the value by creating competing products that are less differentiated. Debasement of any product in the market is the first and the unkindest cut of all in a marketplace. Vilify the product, demonize the brand or hurl baseless invective by flooding the airwaves and you change the value proposition of the consumer.

Okay, so those who have followed the trend can easily see where I am going with it. Here are the nine factors in the making of a commodity:

ONE
1.       Debase the name. But the long tradition of what the words “doctors” and “physician” represent are difficult to eliminate from the mass memory. So the elite take a swipe and gradually change the title to “Provider.” Ah it is catchy and they use that in various media, oozing slowly into the mindset of the populace. As time goes on the “provider” term starts to take on the nurses and then the home care givers, the technicians, the transporters and the house-keepers. Everyone who might have an iota of influence in being involved in a hospital, private clinic or in a university, is a “provider.” When everyone becomes a provider then everyone in the eyes of the beholder has similar value.  You ask, “who’s my provider?” The answer might surprise you.  And surely as I write this, I find that a certain expert elite named, Ezeke Emanuel, MD of University of Pennsylvania as stated that 80% of all medical care can be provided by Nurses, Physician Assistants, or Nurse Practitioners.  And they are now making noise for equal pay for services they render with less education- so much for cost control here… http://content.healthaffairs.org/content/29/5/893.full Huh? Really? Oh but wait, the NPs, PAs and others are rallying behind that cause because they get to be “doctor-providers.” And many wear the white coats and hang their stethoscopes around their necks as they arrive. (And I am not going to make a disclaimer or a politically correct statement here either). http://www.thedailybeast.com/articles/2013/05/27/nurse-practitioners-playing-doctor-more-often.html

Are they up for the challenge?

TWO
2.       Next create guidelines to minimize differentiation in what the “Provider” can do. That reduces the underlying principles of the “Art” in medicine and turns everything into a “soft” science. (And I am being nice here the real word is “pseudoscience”).  So elites and experts now create massive amounts of guidelines in how to treat illnesses. But, and you might have guessed it, they forgot the individual patient. You see no two patients are the same and none ever fit into a category or a cubby-hole. The “Unum” is very much alive in the e-Pluribus Unum. Yet the march to dedifferentiate continues at break-neck speed, maiming all and any defiance. http://www.acponline.org/clinical_information/guidelines/guidelines/

THREE
3.       The third arrow to take flight against the doctor is the new art of “Choosing Wisely.” The concept is so convoluted and does not fit good medical care in the majority of patients that at times it appears that some other element, not being mentioned is the driver behind that program. Everyone falls to their knees and prays to the neon gods and those that don’t are taken to task. http://mdredux.blogspot.com/2014/03/is-this-what-abimfs-chossing-wisely-is.html And  … http://www.medpagetoday.com/PublicHealthPolicy/GeneralProfessionalIssues/45286

FOUR
4.       Meanwhile as the commoditization of medicine is in full swing, a constant harping about costs and how the US is far behind other countries in health and survival outcomes is drummed into the spongy brains of non-critical thinking crowds that are busy trying to make ends meet. The graphics are titillating; the charts are colorfully expressing the desires of the experts and the elites, they show; US medicine is subpar and more expensive. But no one, no one looks at the cost drivers. http://publichealthonline.gwu.edu/us-health-care-vs-the-world/
They seem to hone in on the doctors (here they call them “doctors” and not “providers” to complete the image). Meanwhile the drivers of hospital care and the newly discovered pharmaceutical drugs and the latest innovative devices
and the Administrative Costs remain unmentioned. Only the physician is under the magnified scrutiny!

5.
FIVE
On the one hand there is this crush of cost related difficulties and the “fortunes of a great nation is at stake” and the entire fault is laid upon the shoulders of the doctors (er, providers). And as surely as the sun rises, other mandates are drummed up including Electronic Medical Records (EMR). EMRs have created another gulf between the doctor and his or her patient and the value of the doctor through this enforced interaction has further minimized the value of a doctor/physician in the eyes of the patient. However as many have pointed out that EMRs have created larger barriers in medical care and added to the complexity, reduced efficiency and exacerbated the costs (that the experts want to reduce). The drumbeat of progress continues. Oh well! http://www.kevinmd.com/blog/2013/08/sad-state-emrs-harm-good.html

6.      SIX

2.
The same experts that prattle on about the symbolic “f” of a certain “x” now bring the two together in another well-advertised episode of “f(x)” by using the self-enriching models of creating such endless hardships of NO utility as the Maintenance Of Certification (MOC) for doctors. The “x” here is the biannual expense of $5000 cash outflow for the doctors to the inflows for the American Board of Medical Specialties and the “f” in this examination is deemed as means for the doctors to be tested for their knowledge and abilities. Huh? Knowledge and abilities tested every 2 years? The makers of this MOC test (x) propound that the public deserves to know that their doctors are knowledgeable. Indeed the doctors have to fulfill the Continuing Medical Education credits of 50 hours per year to maintain their license in the states they practice and that is the “f” of the test of practicing medicine “x.” But these self-serving agencies have now put themselves right in the middle to promote themselves as the arbiters of physician knowledge. What is most interesting is that there is not a single shred of real “EVIDENCE” that the tests that they profess to be the greatest thing since sliced bread for detecting “unknowledgeable” doctors have any proof. But they carefully craft the queries to the willing about how they “felt” the examination helped their knowledge base. So the “x” here is in place in the form of MOC and the revenue stream to the agency and the “f” is grinding out the template of acceptance and acquiescence through enabled doctors (selection bias) who will affirm the “x.” What is not mentioned that the ABIM a branch of ABMS brings in more than$49 million/year and the President of ABIM makes about $750,000/year. The “f” of this “x” is plain to see, isn’t it? 3. Healthcare cost has been the topic of conversation for several years now. Yes, it is spiraling and you know why? Because it is an incentivized system of care. The misplaced responsibility onto the middle man (the Insurers, Medicare, Medicaid) to pay for any and all ailments of the elderly and the indigent. This incentive creates a sense of entitlement. The doctor’s offices and the Emergency Rooms across the country are bursting at the seams with patients who have arrived there with every minor ailment that time can heal. But what is lost in the jungle of honking noses, dried out coughs, red cheeks and low grade fevers are the real medical horrors that have difficulty being seen by the physician. So cost containment is a need. If responsibility is shifted to the patient for a larger portion of payment and the rush to the emergency room will most likely be reduced. But no, the experts have taken a different tack. They are refusing to reimburse the entity that cares for the sick by denying reimbursements for re-admissions, for infections that become evident during hospitalization claiming them as a result of hospital error and the like. The votes seem to propel the politicians into this circuitous thinking of find the wrong “f” for the “x” all the time. Find the fault with the physicians or providers as the doctors have been demoted to nowadays. These same experts burying their heads in the sand find arcane and clever ways to arrive at reasoning that we should not be trying to diagnose an illness too soon as it causes unnecessary tests and potential harm. They go against mammography (breast cancer screening and PSA test for prostate cancer suggesting “lead time bias” as the root cause of too many diagnostic errors. They also have determined colonoscopy is an over utilized screening tool. But then studies recently have shown an overall dramatic reduction in colon cancer as a consequence of the screening colonoscopy. They flood the digital and printed ink universe with their version of the “f” (harm) for the “x” (costs). Who is the general populace to believe? The current vogue answer to that question is; the adoring media and its “Made to Stick” format and their "Buy-in." A travesty upon travesty! EMRs. Now here is an “x” that was contemplated at the political level through the arbitrage of the experts willing to create the hardware and software for self-aggrandizement at a large scale. So they duped the consciousness of the physicians and the general populace into thinking that the Electronic Medical Records would reduce errors and give a better handle over the disease to the doctors. Did it? Simple answer: No! Did it create a gulf between the physician and the patient? Answer: Yes! But for the “f” in this “x” which was done for monetary gains of the companies that got the contracts, it seems that the physician practices are in disarray due to complexities of the EMR and its meaningless use after spending thousands of dollars that they have been refused reimbursements for by the agency. It has created a mound of useless verbiage through “cut and paste” in the medical records that are done to satisfy some arcane rule of the insurer for documentation and the most devastating of all, it has taken the eyes off the “Ball” -the patient. The eye to eye communication no longer exists and the patient drones on about his or her ailment while the doctor is busy trying to fit round pegs in square holes in the arcane digital universe. This paradigm shift in patient-care is uniformly destructive to the field of medicine. The holistic view however of human care is in the understanding of another’s dilemma and then to solve it through knowledge, experiential reference and a pulse on the frailty of the other. It is not as some experts will have you believe that medicine is but a ceramic/silicon away from being dehumanized and perfected. Kahneman and Tversky famously discovered the utility of the “f” of “x” and not “x” itself. In other words, the relative rise in the utility of one’s wealth as measured by the benefits had a far more meaningful nuance than sitting atop a mound of coins as Uncle Scrooge. You see, the small incremental “f” of “x” have a larger core of happiness in it then a large “x” sitting in a vault that these experts are accumulating on everyone’s dime. The “f” today is manufactured, sometimes created out of thin air similar to printing money by the FED. The artificiality of this “Goldilocks soft-landing” will have a price to pay in the end. The “x” here unbeknownst to most is the lost asset of many trillions by the middle-class, and the ÿ" here is the white-wash, but that is another story… Know your “f” of “x” that is... Live only to accumulate the “x” off of others by a false “f’ prophet and one day not too distant in the future the Lorentz Strange Attractor will have your head for the false "f." THINK! ## Tuesday, April 1, 2014 ### THE PERFECT HEALTHCARE MOUSETRAP The wish for healing has always been half of health - Seneca You finally get into the exam room and your physician enters and greets you. For a brief moment he looks at you and then his head is turned towards the computer screen. He asks questions and you answer in a sort of mechanical way. There is very little reaching across the divide. When he is done he briefly examines you and then writes an order for a test. He smiles and wishes you well, you see him turning back to the computer screen and frowning at the blinking message, as a nurse escorts you into another room, where you sit while the office staff member call various agencies to gain authorization for the tests the doctor has ordered, so you are told. A half an hour later the nurse comes in and apologizes that the insurance carrier has refused to pay for the tests today and that you might have to go to another facility or return again should the insurance company prove to be accommodating. Welcome to the Mousetrap! Nay welcome to the perfect mousetrap! The perfect mousetrap is one with four corners, a door and no exits. The mice are supposed to be baited with peanut butter and then disposed. Now let’s look at the this healthcare trap. The four corners represent the four sentinels guarding the boundaries and the trap is laid for the physician-patient duo. The lure of this intriguing mechanism is its gilded bling as expressed by the designers. This, “they” say, is the perfect lodging for the practitioners of this noble of professions called medicine. Who are “they?” You might ask. And the answer will reveal itself shortly… Healthcare costs are high in the US. But is it all about the doctors providing the care? Seriously comparing Sweden or Switzerland with the US one is really comparing apples and oranges. The personal responsibility is taken seriously in those countries. They exercise and have a limited diet, hence their life spans are better. Not because of the wonders of the healthcare dollar but by their own volition. Ah but the experts won’t tell you that. Besides there is very minimal if at all any discoveries, experimentation, innovation that is being generated from those countries, yet the drumbeat goes on to serve a purpose. The first corner and wall is inhabited by the Federal Government with the likes of HHS, CMS (Medicare and Medicaid) and now the IRS. The initial buy-in in 1965 by the populace was that Medicare would provide care for the elderly at a reasonable affordable cost – a kind of a safety net. Those that could not pay would receive the Medicaid benefits free of costs. Well realizing that most doctors were not enchanted with the formula since the patient would spend the reimbursement checks and the doctors would be left holding the empty collection bag. The HHS/CMS came up with a solution for the doctor buy-in with “accepting assignment.” The logic was that the physician would get paid directly for services rendered, albeit at a lower rate. This seems good on its face since collection issues would be rendered moot. And so it went until SGR formulas were created to limit reimbursements to the physicians and over a10-year period while the cost of living continued to rise as all federal employees and private sector employees garnered the appropriate increase in revenues, the doctors were mired in the perceptible risk of being raked over the coals with a 21%, then a 24% and now a 30% cut in reimbursement fear tactic. Each cut faced a deadline and the doctors held their collective breath each time. But each time the dark clouds passed since Congress realized the drama that would unfold for the Medicare beneficiaries as doctors would stop accepting Medicare. But now, get this, now the government through its agencies has decided to determine the right cookbook methodology of treatment for all high reimbursable ailments. It is now determined by experts like Ezke Emmanuel that 80% of the care can be rendered by Nurse Practitioners and Physician Assistants, so why educate more doctors. Plus, and this is a big plus, reimbursement for the NPs and Pas would be lower, hence the healthcare costs would be lower. But no one has ever looked at the real costs of healthcare and where the money is flowing. For every$1, 12% goes to physicians for services rendered and expenses. 36% to the hospitals, 35% to the pharmaceuticals and device managers, 17% goes to administrative purposes. Oh and if you missed this, you might want to know that CMS (Medicare and Medicaid) spends $385 billion annually on administrative expenses to its own employees. The second corner belongs to the Private insurers and the Hospitals. I lump them in one as the lobbyists groups from both are strong and tend to change the Congressmen and women’s minds about how much they should be paid. While paying millions of dollars as benefits to its upper managers, the insurers and hospitals cry poverty in front of the lawmakers. ‘We cannot survive this without charging a higher premium or lower corporate taxation or both.” And there are many more excuses. The insurers delay, and deny payments to the physicians and at times to the hospitals making them jump through hoops that take time and effort away from actually helping patients. The hospitals in their theatrics, cry poverty and throw the risk of closing their doors and hurting the large community of hundreds of thousands if they don’t get the proper reimbursements through their active lobbyist the American Hospital Association. And every congressman or women knows that (s)he will never be reelected should this come to pass that the hospital will close its doors. No, not ever, Nyet! Meanwhile the cost of a single aspirin charged by the hospital to the private insurers goes to$50, which they collect from other write-offs in their ballooned 10Ks.

And equally befuddling is the United Healthcare’s recent payout to a New York Podiatrist for $178,080.00 for surgical repair of two hammer toes that took less than an hour. Truly the left hand does not know what the right hand does! And to rub this wound into a mound of salt, the reimbursement for a open surgical cholecystectomy (gall bladder removal the doctor makes between$485-745 for the surgical procedure and the 90 day of care thereafter). Go figure that out!

The third corner and realm belongs to a new rising star in the private arena and it is the American Board of Medical Specialties and the American Board of Internal Medicine. These two entities have crafted a calculated strategy of requiring physicians to pass the Certification examinations in the specialty that the physician practices medicine. The physician buy-in initially was that they wanted to distinguish themselves as having achieved the “Board certification status.” If you were certified, you could keep that certification for ever. Recognize that phraseology? The revenues to ABMS and ABIM were modest and so they determined the revenue cycle had to be modulated to yield higher values. Enter the need for re-certification.  After 2000 everyone would receive a time-limited certificate of 10 years. Doctors entering the medical arena did not know any better so accepted the formula, while those grandfathered kept quiet. Now however, even time unlimited, (grandfathered) certificates will also need re-certification.  Ah, but that is not all, the revenues recovered from just the re-certification consequently doubled from this minor fiat, but the ABMS and ABIM were not done, they, then created the Maintenance of Certification or MOC as it is called, rule. Every two years a doctor would need to fulfill the criteria of MOC and only then they would be allowed to take the re-certification examination. Well then the 2010 revenues of ABMS rose to $49 million and the salaries of their President went to$750,000.00. Turns out that the president Christine Cassel MD (who had not practiced medicine or never was recertified) also happened to be on patient safety commissions and other boards influencing the needs of the certifications and the MOC processes (No one saw the conflict of interest, until maybe now and that scenario has yet to be played out). The conflict of interest was recently discovered and investigation is ongoing. But here is the kicker, MOC, no less the Board certification has NEVER been proven to show that a certificated physician is a better physician than non-certificated ones. (Disclaimer: I was certified in Internal Medicine and twice certified in Medical Oncology) I have never found that my expertise or knowledge was ANY BETTER than those who had not sat through this examination.” And what does ABMS have to say about the benefits, "MOC is recognized as an important quality marker by insurers, hospitals, quality and credentialing organizations as well as the federal government."  (Nothing about patient care or patient outcomes or patient well-being or differentiating quality of healthcare rendered by certificated and non-certificated physicians, however they imply the potential but are unable to provide a factual impartial relevant study.) So, what gives? Money, as in $that one would quickly guess. And to formalize and ossify the need there is a continuous push by the ABMS and the ABIM to make MOC the necessary criterion for Maintenance of Licensure in each of the 50 States so the revenue cycle continues unabated and increases with each passing day. Oh and if I haven’t said this before, did you know that the pass rate of the certification examination just started to fall in the last two years. Why? You ask....Elementary my dear Watson they fail the physicians so that they have to come up with the$5000 again for the next year examination…Another productive solution to increase the ROI (Return on their Interests), Top line and Bottom line for these unaccountable entities. Wikipedia states: "Maintenance of Certification (MOC) is the process of allegedly keeping physician certification up-to-date through one of the 24 approved medical specialty boards of the American Board of Medical Specialties (ABMS) as well as some of the medical specialty boards of the American Osteopathic Association (AOA).[1] Some studies, funded and performed by highly conflicted employees of the member boards, have shown that board certified physicians deliver may higher quality care than their non-certified colleagues and that board certification is correlated with." :
The legal eagles spend $1500 per capita in PAC money to lobby the Congress so as not to allow any bills on Tort reform, cap damages for pain and suffering and definitely not consider those filing frivolous law suits should have to pay the court fees. No that would hurt the poor indigent people who have been wronged they preach. No, never, that will never pass, because the trial lawyers (And Shakespeare had them right on) do not wish to let this golden goose lay its eggs in another’s basket. Thus the tort reform sits and sits while Law firms hire and hire and get bloated with hundreds if not thousands of lawyers in each firm, while the solo practicing doctor finds it difficult to keep his or her practice open. By the way a Trial by Jury is unheard of in non-criminal cases in most if not all other countries except, you guessed it, the United States. And that now brings us to the two little people in the middle, “The patient and the physician.” The one that ultimately suffers from all these concocted mechanisms of care delivery is the patient. He or she will ultimately pay for limited, substandard care while the doctor is made to become a secretary to check boxes for the governmental mandates and get the insurer’s pre-authorization checklists toiling away to build a large database for the enormous Big Data warehouse so that analytics will define what is and what is not medicine. The patient will pay more out of pocket because that is the next step to limit access to the doctor or the emergency room or the hospital and he or she will pay more in premiums to pay for those that do not or cannot pay for insurance coverage. Not only is the patient in danger of sub-optimal care as a consequence of this recipe-style medicine but he or she is also at risk of being marginalized for proper care if the costs outweigh the productive benefit as it is related to age and ability. Lastly the doctor, he or she will have to live by the cookbook style of guidelines in medical care, thus going against the Hippocratic oath at times, especially if (s)he is a hospitalist and the job depends on a productivity contract. Admissions in the hospitals are being scrutinized and hospital stay days are the metrics for reimbursement by the CMS in most areas thus discharging patients in an untimely fashion to garner a larger margin from the admission might jeopardize the patient’s health to say the least. The constancy of cost as it relates to care might become the overriding concern of most hospital employed physicians who want to go-along to get-along and maintain their job security. Medicine will fail and that is exemplified in the National Health System (NHS) in the United Kingdom where there is nary a day when some hospital, a part of the NHS, isn't shown to be understaffed, dilapidated structurally, where employees show lack of concern with the conditions, patients and at least in one hospital where aborted fetuses were burnt to heat the hospital interior- their new HVAC system! So there you have it, the perfect healthcare mousetrap that will catch a lot of sub-optimal, substandard, sub-par healthcare for the patients that fall into the trap. Please think beyond today and beyond your paycheck. This format hurts everyone. It rips the nobility in medicine, destroys the faith between the healer and the patient. It renders moot humanity and glorifies the silicone chip and the almighty$dollar\$.