It began with a cough.
Which became pneumonia, a small stroke and atrial fibrillation.
The patient? My 90-year old Mom. Perfectly fine partying with family at Christmas, two weeks into the New Year she was suddenly in an emergency room with all kinds of tubes, wires and needles running in and out of her. Possessed of extraordinary good health -- her last medical run-in almost 30 years earlier -- abruptly she was in the middle of the most hotly debated political issue in America: the American health care system.
Which meant, of course, that as her only child I was now along for the ride as well.
This journey (she's recovering in sturdy fashion -- and yes, she had insurance) brought us into contact with exactly what's right about American health care -- and a doctor who has been trying and failing to get the attention of elected officials to discuss what's wrong. That doctor is, in the aftermath of the Scott Brown rebellion in Massachusetts, the very embodiment of why so many Americans are so furious about the handling of the health care issue. According to the latest Gallup/USA Today poll, "An overwhelming 72% of those surveyed Wednesday say Brown's victory 'reflects frustrations shared by many Americans, and the president and members of Congress should pay attention to it.'"
Case in point: James F. Rich, MD, a partner in Connor, Rich Associates, a Heritage Medical Group practice in suburban Harrisburg. Dr. Rich, along with his colleagues Dr. Robert Kusztos (her longtime physician) and Dr. Claudette Jatto, have gone above and beyond the call for Mom. Not to mention Denise the Dallas Cowboy fan and blood tester extraordinaire. But there was something else here as well.
Sitting bedside for what seems like endless hours in a hospital is something many Americans experience somewhere along the line. In this case, I was lucky. As Dr. Rich made his daily calls on Mom, the television overhead reporting in increasingly astonished tones about the emergence of Scott Brown in his now famous race for the U.S. Senate against Democrat Martha Coakley, conversation turned to the obvious. What did Dr. Rich make of all this?
The answer astonished.
It seems that Dr. Rich, a thirty-year specialist in Internal Medicine who spends every day of his working life "caring for adults and dealing with acute and chronic disease," was so disturbed about the turn the health care issue had taken that he had begun devoting considerable off-duty time to writing a white paper on the subject. "I'm not a writer," he told me somewhat sheepishly, as he described his unsuccessful attempt to bring the results of his work to the attention of his elected United States Senators -- Pennsylvania Democrats Arlen Specter and Bob Casey.
"Did you send it to them?" I asked?
Well, actually, Dr. Rich had done better than that. He personally took copies to their Harrisburg offices -- and never heard a word from either Senator. He had gotten it to Republican Congressman Todd Platt, who did respond -- but Platt, of course, sits in the House of Representatives run by Nancy Pelosi. So much for that.
I was incredulous. Dr. Rich may not be a famous TV doctor, but he is in fact a highly respected practitioner in this Pennsylvania community. And no response on the most important issue of the day from his two U.S. Senators, both of whom are staunch Obama supporters and of ObamaCare? None? Zip?
That is correct.
The treatment of Dr. Rich, in effect just blowing him off, is in fact emblematic of precisely the frustration profiled in that Gallup poll. It is exactly why Massachusetts voters responded so well to Scott Brown. Like Dr. Rich, Massachusetts residents were doing everything they could to tell their elected officials there was a better way to do health care. They felt no one was listening. Not the President. Not Nancy Pelosi and Harry Reid. And in Pennsylvania, in spite of those raucous televised town meetings where Specter parried with angry constituents, not Specter or Bob Casey, Jr.
What kind of people were the President, Reid and Pelosi really listening to?
Behind close doors they were listening to powerful political cronies. To lobbyists. They were making deals, from the Cornhusker Kickback of Nebraska Senator Ben Nelson to letting union members off the hook for taxes on so-called Cadillac plans, a favor denied every other American who isn't a union member. The louder the protests from average Americans, the tighter Washington closed the doors. Typically, in one of the more vivid campaign blunders that helped Scott Brown to victory, Democrats sent word to Martha Coakley to get herself and her Sure-Thing campaign off the campaign trail to fly to Washington for a fundraiser held by fat cat Washington lobbyists at a fancy Washington restaurant. She did. Was Dr. Rich there? Were the average voters of Massachusetts who were so upset about health care invited? No, of course not.
DR. RICH IS A DOCTOR practicing medicine everyday in Central Pennsylvania. He's not a lobbyist. Never in a thousand years would people outside the Beltway like Dr. Rich get invites to this all-too-typical type of Beltway Insider soiree. Who was Martha Coakley listening to at this event? The lobbyists, of course. The Insiders. Meanwhile, Scott Brown was driving his truck all across Massachusetts talking to the Outsiders, the Dr. Jim Rich's of his own state. Doubtless he encountered doctors just like Dr. Rich. Obviously there were a whole lot of other Bay Staters who weren't being listened to either, and they sure weren't all doctors.
In The Fatal Conceit: The Errors of Socialism by the great free-market economist and Ronald Reagan favorite F.A. Hayek, Hayek approvingly quotes a 19th century British economist as saying that an economic enterprise -- and medicine, whatever else, is distinctly that -- requires "minute knowledge of a thousand particulars which will be learnt by nobody but him who has an interest in knowing them." Or, to quote Mom after a week of being tended to by Doctors Rich, Kusztos, Jatto, plus cardiologist Dr. Stanley Lewin and a bevy of nurses: "I'm amazed at how much these people know."
So. Let's take a look at some of the "thousand particulars" Dr. Rich has been trying to bring to the attention of government officials, moving from the general to the quite specific.
• "A national health system is not the answer to the health care crisis."
• "I do not believe that we need another way to pay for health care in this country, but we do need a better way to deliver and utilize it."
• "Any government health care program has shown to be inconsistent with a limited government and respect for individual liberty, thus, it would simply be a massive wealth redistribution scheme."
• "Embrace" the system, keeping "the good elements and change the poor ones."
• The government portrays medicine not as a commodity but "a perceived right of the individual." This government "regulation of the health care industry, (the) rise of third party payment systems, and the birth of managed care" have in turn resulted in "a complete absence of any environment in which physicians and patients have to make cost effective choices."
Gee. No wonder they don't want to listen to him.
Most importantly, Dr. Rich says his experience has taught him:
First, differentiate acute care from chronic care. (For the layman, a heart attack involves acute care. Treatment for heart disease involves chronic care.)
Second, make far better use of tele-medicine/tele-health programs in both rural and urban settings.
And number three? Dr. Rich boldly cites a particular that may terrify some because of its sheer political incorrectness: "We should explore…the impact of spirituality and volunteerism."
Last but not least, Dr. Rich makes the obvious point: the patient "is ultimately responsible for their health maintenance.
Here are some of his particulars -- and he has a lot of them. It should be said here that not by any stretch does Dr. Rich pretend to all the answers. But Rich's paper (not to mention Rich himself) is a fountain of research and statistics that he has combined with his thirty years of hands on experience. In the style of a well-researched physician, he cites chapter and verse of studies that back up his conclusions.
For example, to enter Rich's world of data and "a thousand particulars," John Wennberg, M.D., M.P.H. of the Dartmouth Atlas Project, did a review of the records of 4.7 million Medicare enrollees who died between 2000 and 2003 "and had at least one of twelve chronic illnesses." "Even this limited study", says Rich, showed 30 to 35 percent of Medicare dollars are spent on chronic disease management.
Which leads to the obvious question: why are hospitals being used as the first line providers for chronic care?
They are -- all across the country. This is standard fare in any modern hospital -- and shouldn't be. Not only is this a preventable waste of billions of dollars (about $40 billion to be exact) -- this practice actually can worsen the outcome for the patients. In other words, to personalize, if Mom's condition does not improve and shifts from the acute category to the chronic category -- the best place for her, the safer, better-managed and less expensive place -- is not the hospital. Where is that place? For Mom, it will be home, where I will do the "managed care" with help from outside -- physical therapy, in her case. But for others it could be, for example, a managed care facility, a nursing home or a hospice.
Let's stay on this a second.
Just one set of savings of $40 billion has been pinpointed by the research of the Dartmouth Project. No trillions need be spent, no taxes raised, no freedoms and liberty lost, no massive, tax-fueled and bloated bureaucracies created. A different approach entirely could save $40 billion. Just for starters. It is beyond rationality to complain that the cost of health insurance is too high while shrugging off a serious effort to reduce the costs that insurance is designed to cover -- thereby reducing the cost of the insurance itself. Is this what was discussed behind closed doors in Harry Reid's office? Who knows? Did the subject ever come up? Who knows? Was a real opportunity missed to educate the American people (as I was educated by this experience) on a subject they have perhaps personally encountered in dealing with their own health care or that of a family member -- without understanding what they were seeing? Yes. Was an opportunity missed to have people like Dr. Rich educate Washington politicians on a problem they could not possibly understand from first-hand experience (as Hayek's economist noted) unless they themselves were doctors? Absolutely.
This is what happens when there is no transparency, when people like Dr. Rich -- deeply knowledgeable Americans with extensive hands-on experience -- are excluded from the legislative process in favor of a wild-eyed, fanatic insistence on closed-door meetings and secrecy. If there were a C-SPAN version of "American Idol, Medical Division," Jim Rich would be Susan Boyle, the Scottish matron who became a star because attention was finally paid to her singing ability. In a country of over 300 million, it isn't possible to believe Rich is alone in this category, either.
But the Washington response? Like a child having a temper tantrum, hands over their ears, the essence of the response has been to refuse to listen. To Dr. Rich, to the people of Massachusetts and all the rest of us. Instead, doors closed, people were kept out of the process if they didn't have an approved point of view. Post-Massachusetts, one can only ask: does the Obama/Reid/Pelosi corner get it now? Do they understand?
DR. RICH HAS PLENTY MORE in the way of ideas to reduce the cost of health care -- and quickly. Rattling off detailed particulars like a Gatling gun he discusses thoughts on when to hospitalize a patient, the criteria for admission to Intensive Care Units, when patients should be referred to medical specialists, when to order diagnostic/imaging tests for patients at given stages of a chronic illness, whether more resources equals better care (hint: no), and the need to invest in comprehensive home health care services. He discusses the need for reimbursement policies for health care providers to prevent health care problems, instead of paying for doing tests and procedures. He focuses on the role of information technology, in particular the startling uses of tele-medicine. (One study from Sam Burgess, PhD. of the University of Tennessee Medical Center is particularly remarkable in demonstrating startling decreases in everything from hospital admissions to days spent in the hospital to readmission rates to, of course, costs. In passing, Dr. Rich also mentions the ability of a doctor to step into a high-tech booth in Harrisburg and remove the uterus of a woman all the way across the state in Erie. Can I be alone in finding that astonishing?)
Let's focus on something else Dr. Rich has found that you can bet would not be a subject of discussion at a lobbyist-hosted Washington fundraiser for Martha Coakley, something that Scott Brown and others who are forcing the health care discussion back to square one should be looking at.
Says Dr. Rich: "The third example one can impact is quite atypical when discussing our standard conventional-type medicine. This is spiritual medicine and volunteerism." In short, he has done the research here and found "multiple studies from Duke University where considerable savings and decrease in morbidity and mortality is supported by strong scientific data." One of those studies, by Dr. Harold Koening, the co-director of the Center for Spiritual Theology and Health at Duke University Medical Center, selected 75 out of 150 patients scheduled for heart surgery, both patients and doctors unaware of the selection. Koening, says Rich, "randomly chose a name and sent it to a spiritual group such as a Buddhist monastery, a Catholic Convent and Protestant and Jewish denomination spiritual groups. He requested these groups pray for a particular patient. From the 75 prayed for, almost all of them spent one less day in the hospital, used less blood transfusion, and had requested less pain medicine."
Talk about a radioactive finding if you're a liberal lobbyist! Extensive findings that demonstrate that "people who attend congregational religious services once a week have a longer life span than those who do not"??!! Mom, as noted, is 90, and will be 91 in June. She has spent a lifetime as an active member of her church, and up until her illness was attending our church every Sunday -- like clockwork. And of course, her pastor, the Reverend Galen Russell III, stopped in to check on her. Members of the very Protestant United Church of Christ, the descendant faith of the Pilgrims, the major hospital for us is Holy Spirit, a fabulous place run by the quite Catholic Sisters of Christian Charity. In one vignette of her stay, while a Catholic nun came in to call and ask if she could offer a prayer, Dr. Lewin the heart doctor stopped in -- wearing his yarmulke.
One has a hard time imagining this last vignette -- Protestant patient praying with a Catholic nun while a Jewish doctor waits patiently, head bowed -- in any government-run health care system. Not to mention Koenig-style organized prayers as treatment. The ACLU would have lawyered up before the day was out, effectively closing out one avenue of treatment Drs. Koenig and Rich have found to be very, very important. One can only imagine where an idea like faith-as-treatment would wind up in a behind-closed-doors writing of a health care bill with Nancy Pelosi and Harry Reid. No wonder Dr. Rich's proposals seem to get lost. How does Rich see this translate in the real world of health care policy? Linking up insurance companies with clergy, churches, and "volunteers from faith-based communities and institutions" for innovative partnerships.
THE ELECTION OF SCOTT BROWN -- and the lack of response by Senators Specter and Casey -- shows in a snapshot exactly what the American people see as the core problem with the health care issue. Are there problems in the system? Yes. But even in Massachusetts people want no part of a federal takeover of the health care system.
They are fed up with what they perceive as a mind-boggling arrogance that deliberately shuts out average Americans like Dr. Jim Rich because they have an entirely different set of beliefs from the Washington establishment or simply don't have the right connections. A poll by the Washington Post, the Henry J. Kaiser Family Foundation, and Harvard University's School of Public Health released over the weekend quite specifically notes: "Among Brown's supporters who say the health-care reform effort in Washington played an important role in their vote, the most frequently cited reasons were concerns about the process, including closed-door dealing and a lack of bipartisanship." To wit: shutting the door on Dr. Rich.
Whether the lack of a response from Specter and Casey is a simple case of a prominent constituent's views somehow getting lost in spite of his effort at personal contact, or whether it's something more, the non-response is easily seen in this environment as arrogance. Two U.S. Senators, Democrats both, who have made it emphatic they side with their President and ObamaCare come hell or high water, can easily radiate disdain for dissent to their staffs. This kind of thing can only be a liability for Specter, already in trouble in the polls. Switching parties as defeat in a Republican primary loomed, it's as if he leapt to the deck of a political Titanic thinking he was saving himself. The latest Rasmussen poll has him trailing the Scott Brownish Republican Pat Toomey by 49-40 percent, numbers that will not be helped with Specter's well-publicized put-down of Minnesota Rep. Michele Bachmann, exemplifying in one well-replayed radio interview the perceived arrogant attitude in Washington that drove the angry response from average Americans that was the Brown rebellion. Bachmann, inevitably, immediately responded to Specter with an accusation of "stunning arrogance." It should be noted here that Bachmann appeared Monday night on The O’Reilly Factor and said Specter had called her at her home to personally apologize. Good for him. Regardless of his bid for re-election, the Senator is a major player on health care issues because of his position on the Senate Appropriations Committee’s Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, and as such one would think him eager to learn from someone like Dr. Rich.
But Specter and Casey aside, Dr. Jim Rich persists, ignoring the political circus and quietly moving forward regardless. This week he has arranged a meeting with Capital Blue Cross, one of Pennsylvania's largest insurance companies, to discuss the hospital readmission problem and a better compensation system for home care. He has applied his considerable professional experience with deep research and serious intellectual curiosity. He has discussed the issue with everyone from the head of the Royal College of Physicians and Surgeons in Canada to leading medical technical professionals in Germany to his own daughter, a medical student in London. Having studied medicine in Italy -- where he spent six years learning about a socialized medical system -- he has spent the bulk of his time doing the hard work of taking care of everyday, average Americans with every manner of problem under the sun.
If Scott Brown succeeds in being the 41st vote in the U.S. Senate that puts a stop to ObamaCare, and really believes that the place to start is from scratch -- then one of his first contacts should be with Dr. Jim Rich.
Why? Because exactly like Scott Brown, Dr. Jim Rich (firstname.lastname@example.org) has got it right. We can do better. Much better.
Not to mention, Mom can recommend him.