Let's Promote Adherence to Compliance

While I'm ranting about semantics, I've got another nit to pick, only this one is with an insidious faction lurking within the medical community itself. This issue, which has been showing up in medical journals over the last couple of years, has to do with the replacement of the term compliance with the term adherence when referring to the concept of patients' following the medical plans and recommendations that we physicians provide to them.

Let's start with the definition of these terms, in both English and in "Medicalese":

Adherence -- ENG: the process or condition of adhering; to cause to adhere; make stick; which leads to Adhere -- ENG: def 3 - to carry out a plan, scheme or operation without deviation

Compliance -- ENG: act of complying with a wish, request, or demand; with a
medical definition from an English dictionary stating: "willingness to follow a prescribed course of treatment"

Sound pretty similar, don't they? In fact, they sound like synonyms.

But somehow when these word get translated into "Medicalese", the definitions get deformed. As taken from the online Stedman's Medical Dictionary:

Adherence -- MED: the extent to which the patient continues the
agreed-upon mode of treatment under limited supervision when faced
with conflicting demands, as distinguished from compliance or maintenance

Compliance -- MED: the degree of constance and accuracy with
which apatient follows a prescribed regimen, as distinguished from adherence or maintenance

In the English language dictionary, the two words have very similar meanings, namely, the process of or willingness to carry out an established plan, in this case the medical plan established by the physician.

In the "Medicalese" dictionary, the two words all of a sudden have different meanings; they are actually set against each other (as distinguished from) as being specifically different. is it any wonder that people at large think we physicians speak another language? It's because some of us (the ivory tower academics) think that we do, to the point that they are redefining words! They must have forgotten that these words already have definitions that have been around for centuries.

Adherence loses the property of "without deviation" and becomes a matter of degree or extent; compliance gains the property of "constancy and accuracy", which have nothing to do with compliance, and are more correctly scientifically called "precision".

More to the point, in the "Medicalese" definitions, there is an implied semantic (see def 3b again) difference that is not spelled out in the expressed "Medicalese" definitions. In "Medicalese", compliance semantically retains the idea that following the prescribed course of action is a choice of the patient. Adherence semantically is something that is under the physician's control; it is something he must cajole out of the patient, and if the patient does not adhere, then it is the physician's failure, not the patient's.

Thus adherence is no longer responsibility of the patient. It is the responsibility of the physician. Furthermore, since what the physician is trying to cajole is adherence to compliance, and compliance is now a measurable quantity ("degree of accuracy"), then the degree of adherence (to compliance) is measurable as well. And it is a measurable component of the physician's job performance, not the patient's willingness to get better.

In other words, if the patient doesn't follow the treatment plan, it's the physician's fault for not getting the patient to participate ("adhere") accurately enough (compliance).

I object!!!

I object strenuously to the deformation of the English language ("words mean things"). I object because this alteration of word meanings is not accidental, but is clearly designed to further some nefarious purpose. I object to the use of these terms in their altered states by medical journals because of this nefarious purpose. I object to the transfer of responsibility of following a treatment plan from the patient to the physician to support this nefarious purpose. As I have said before, healthcare is a responsibility of each and every person, which cannot be abrogated or assigned.

I say, let's promote adherence ("to carry out an operation without deviation") to the true meaning of compliance ("willingness to follow a prescribed course of treatment" by the patient).

And what is this nefarious purpose, you might ask? In the medical world, it's called P4P. More on this later.

American Cancer Society Please Read This

Four times this morning, I watched as a series of PSA's made by the American Cancer Society played on my TV screen. Now, I like the American Cancer Society. I think overall they have done good work. I've given money and raised money for the American Cancer Society. But I have to take them to task about these new PSA's, and if they continue down the path that they seem to have embarked upon, I soon may no longer be able to support them.

The most egregious of these PSA's begins, "This is what a healthcare crisis looks like to the American Cancer Society." The basic point of these messages is that there are cancer patients who can't get treatment because they don't have any or enough medical insurance. I agree this is a problem. I do not agree with the way they phrase it, however, referring to it as a "healthcare crisis".

American Cancer Society, please read this: There Is No Healthcare Crisis in the United States!

Words mean things. Yes, this is basically an issue of semantics (see particularly definitions 1 and 3b), but it is an important issue of semantics. If people are told enough times that there is a "healthcare crisis", then they will begin to believe there is a fundamental flaw in the actual medical care that is being delivered in this country. And we have the highest quality, most technically advanced healthcare in the world. Qualitatively and quantitatively, the average American receives more healthcare, and higher quality healthcare, than the average citizen of any other country.

Is our healthcare system perfect? No, it's far from it. Let's look at some recent numbers. Of people being treated for hypertension, around 63% are treated to what are recommended as goal levels. Pretty abysmal, huh? Must be a crappy system, right? Well guess what? Almost every other country is far below us, in the range of 31-46% or less. Can we do better? Yes. Must we do better? Yes. But everywhere else in the world has to do better just to catch up with where we are now.

If someone cannot get needed care for a life-threatening illness due to a lack of ability to pay, I would agree that is a tragedy. But the tragedy is not that our healthcare system is in crisis. It is a tragedy because our societal system has led to such high medical costs that many people cannot afford the price.

And the solution to that problem does not involve destroying the best healthcare system in the world. Indeed, we should enhance such a system. It is everything around that system that needs to be changed.

Stay tuned.

President Bush Is Right in Vetoing SCHIP Bill

To President Bush: Yes, PLEASE veto the SCHIP legislation!

For those not fully in the know, SCHIP is the State Children's Health Insurance Program. This is a program designed to provide Federal government assistance (read "pay for") in providing health insurance to children whose family income was below the poverty level and could not afford to buy commercial insurance for the children. In fact, the original legislation called for signing up children whose family income fell below 200% of the poverty level. That number is currently around $41,ooo/yr. Since it's inception, some states have used their funding to sign up children of families with incomes as high as 350% of the poverty level.

SCHIP is up for renewal now, and the (Democratically-controlled) House and Senate are debating differing bills on expanding the programs. Both houses are calling for dramatically increased funding and increased coverage levels nationally to 35o-400% of the poverty level. (That's up to a family income of $92,000 -- among the top 20% of wage earners in the country.) Meanwhile the original programs are not succeeding at their original purpose, as the percentage of eligible children in families below 200% covered by SCHIP is well less than 90%. Leave it to the Congress (and especially the Democrats) to expand a program that isn't even doing what it was supposed to do.

While the Houses of Congress blather about how much more money to pour down the well, President Bush has moved administratively to limit the ability of states to use Federal dollars on any SCHIP coverage to a family making more than 200% of the poverty level until that state can demonstrate that at least 95% of children in the less-than-200% category have some kind of health coverage. Believe it or not, he's actually trying to make a government program do what its enabling legislation says it's supposed to do -- and he's being soundly criticized for it!

President Bush's position is that the SCHIP is supposed to help those who truly need the assistance, and that to expand the program to cover more and more children at ever-higher income levels is just a way to try to surreptitiously expand government healthcare as a back-door to a single payer system. And he's right about this. This is not a new ploy by the Democrats. Recall Al Gore's healthcare "reform" proposal in the 2000 election: Expand Medicaid up and Medicare down (age-wise) until everybody is covered -- a back door to a government-controlled healthcare system.

And lest we forget: Though SCHIP is technically provided through private insurance companies, the program is administered through Medicaid. The private insurers must contract with Medicaid (in each state), abiding by whatever rules Medicaid puts down. It is essentially just an expansion of the Medicaid program. Expanding SCHIP is just another way of implementing Al Gore's misbegotten idea.

If families making $92,000/yr cannot "afford" to own up to their responsibility to provide for the healthcare of their children, then there is something wrong -- with them! They have problems with their priorities, with their budgeting, or with their mental processes. But they don't have a problem with the lack of Big Brother "helping" them.

The house of cards hasn't even completely fallen yet and the communists are trying to take us down the wrong path. The uphill road seems to be steeper than even I imagine.

UAW Strike Fulfills Prophecy

I now stand before you a prophet in my own time. Or at least in my own mind.

As I informed you in my last post, I began predicting the disintegration of the current healthcare financing system ten years ago. The prediction was subsequently refined to indicate that the precipitating event would be a labor strike at a major national employer, which three years ago I determined would be General Motors.

So the UAW's strike fills my prophecy in full.

Even though union leaders say that the real reason for the strike is to get guaranteed job security, I think healthcare benefits must be part of this. After all, what comes along with job security? Healthcare benefits security.

Unfortunately, being proven a prophet has its downside. For the prophecy only begins with the strike against GM. What will follow is the complete unraveling of the current healthcare financing system and its ultimate replacement with something else. My powers of foresight have not yet revealed to me how long this process will take, or what we as a society will be left with at the end of the transformation.

I do know this: our American society now faces a choice of which direction to follow. And it is a choice. Do not let anyone tell you that it is not.

Will we choose to go down the easy path of government-controlled, government-regulated, and ultimately government-limited healthcare, where Big Brother tells you how much healthcare you can have, what kind it is, and how it will be done? Where (to horribly paraphrase Henry Ford) you can have any kind of healthcare you want as long as it's bleak? Where the government decides how much your healthcare is going to cost, and this amount will never cover the true cost, and the quality of healthcare progressively suffers as a result?

Or will we choose to go up the harder path of personal choice and personal responsibility, where you choose what healthcare you want, when you want it, and how much of it you want? Where the decisions about your healthcare are made between you and your doctor with no government bureaucrat standing behind you with a prior authorization denial slip? And where you, not the government or an insurance company, decide how much it's going to cost, and what the quality of that healthcare will be, because you, the actual consumer, are the one paying the bills?

Being able to see a train wreck coming and not being able to do anything to stop it is painful. That's where I've been for the last ten years. It's one of the reasons I started this blog. Before any solutions can be found there must be awareness of the real problems. And I will continue to carry my lamp, as feeble as it may be, to try to bring to light what I see as the nature of the real problems so that hopefully we may come to the right solutions.

America deserves a healthcare system of choice, options, dynamism, and innovation. It does not deserve a one-size-fits-no-one system of limits, rationing, stagnancy, and inhibition.

So my ranting will go on.

The Healthcare Financing House of Cards Is About to Collapse

I was listening to the radio this very morning and suddenly felt very vindicated. Let me explain.

Beginning ten years ago, in 1997, I looked at the state of things in healthcare, particularly healthcare financing, and realized that the whole thing was a house of cards, and not a particularly well-built one at that. I've touched on this in previous posts, but in a nutshell, it goes like this:

Insurance premiums go up and up while covered services get fewer and those covered are restricted through "prior authorization" and the like. Meanwhile, patient copays climb higher and higher, while doctor and hospital payments slide lower and lower. Nobody knows the true cost of a service, not even the doctor providing it, because he's had to adjust his fee so much to make up for what the insurance companies aren't paying him that he no longer recalls what the real cost is anymore. Furthermore, government oversight and insurance company meddling increase the hassle factor of medical practice more and more each year, month, and day. Inflation chops away at doctor and hospital profit from the opposite end from the payors at an ever escalating rate. The liberal elite, controlling the media and thus controlling the argument, proclaims healthcare a "right" (which really it isn't) and leads society into believing more and more that they can have all the healthcare they want, the cost be damned. (Of course what is wanted is not counseling on lifestyle changes to prevent or control chronic disease, or medications to thwart the devastation of diabetes, high cholesterol, hypertension, and the like, but rather cosmetic surgery, Botox for everything, laser facial peels, and other crap that won't add a day to their lives.) Swimming over all of this are the sharks, the malpractice lawyer-jackals, who ravenously feed parasitically off of every part of the healthcare systemwithout any restraint . Looked at globally, the entire thing is unsustainable, and headed for collapse, primarily because the wrong component of the system is in control.

So, ten years ago, I began to predict that ten years hence, in 2007, an event would occur that would make it obvious that the wheels were coming off the cart, that the seams were coming apart, that the house of cards was coming down.

Six years ago I refined my prediction -- I named the event . I predicted that the event would be when a major national employer and its labor union would break off talks on renegotiation of the labor contract, and the union would go on strike, and the camel-back-breaking straw would be the health benefit part of the contract.

About two and a half years ago, I learned that there was a major national employer whose union labor contract would be up for renegotiation in 2007. Even better, this employer was in trouble and had already sought and obtained health-benefit-related concessions from the union. So I modified my prediction even more.

I predicted that the event would be when the union went on strike against General Motors because they could not come to terms on healthcare, the union wanting more, and the employer offering less.

So imagine my lack of surprise when I heard on the radio this morning that the contract between GM and its union had officially terminated last Friday at midnight (three days ago), and it was being continued hour by hour while negotiations continue. And the sticking point?

Healthcare benefits.

I feel vindicated. And a little scared.

Why scared? Because the house of cards is coming down, and with the way things are in this country right now, the obvious solution to the coming crisis will be thought to be the same one that was created for the Medicare drug problem -- let the government take over!

Only that will be the wrong solution. For that will take the control of the system out of the hands of the insurance companies, who have control now, and put it in the hands of the government. Control will go from one set of wrong hands to another set of wrong hands. And those who have the right hands will continue to suffer.

Whose hands are the right hands? My answer might surprise you. It's the patients.

Why Medicines Cost Too Much -- The Government Is Not Here To Help You

I'm finally back to the series on why your medicines cost too much. This time around we're going to look at what many (and they control the news media) say is the solution to the problem -- the ye olde Federal Government. I maintain It is one of the problems, and in many ways.

First off, let's take the Food and Drug Administration (please!). This agency is tasked with protecting the American public from dangerous drugs, and despite recent events with various drugs (Rezulin, Vioxx, Zelnorm, Propulsid, Avandia), they actually are doing a fairly good job of this. After all, the American drug consumer never saw thalidomide (as a morning sickness agent), whereas in Europe many people were born with deformed limbs because of this. And even though thalidomide is now actually on the market (it does have a use for multiple myeloma and certain kinds of resistant leprosy), it is highly regulated and covered with warnings. I of course have no documentation of this, but I am sure there are other medications that we have been equally protected from. It's hard to prove a negative, after all.

Unlike others, who because of the need to withdraw a small number of medicines from the market feel that the FDA allows medications onto the market too quickly, I hold the opposing view. I think they don't approve medications quickly enough. Most of this is because the FDA will not accept foreign (mostly European) safety data for medications and insists that the drug companies do specific studies in the U.S. for them to review. This adds to the already high cost of bringing a drug to market, which must then be recouped. And since a company's patent (and exclusive right to market a new drug) starts when they first invent the molecule and not when they get it on the market, this delay in getting to market shortens the time the company has to recoup the cost. Higher costs, less exclusivity, up goes the price! Meanwhile, some of these drugs have already been on the market in European nations for up to 10 or 15 years! The post-marketing safety data in these countries (or at least those countries we scientifically trust, like England, France, Germany, Spain....) could be used to show that the drug is safe for America, but to my knowledge, the FDA will not accept this data for review.

Another way the Federal government causes escalating drug prices is through its protection of the managed care system. I strongly feel that managed care has never brought down any costs in the medical field, but it sure has saved a lot of money for the insurance companies! In the 1970s, the Congress passed a law commonly called ERISA -- the Employee Retirement Security Income Act of 1974. Though its name does not immediately suggest this has anything to do with healthcare, the law provides certain regulation of employer-provided health insurance programs. Despite the fact that the law does not explicitly provide for this, the health insurance industry has successfully and repeatedly used ERISA as a shield, arguing in court that the federal regulation preempts any state law to otherwise regulate health insurance, thereby preventing state courts (where most malpractice and liability cases are brought) from using state laws to penalize the insurance companies when they deny payment for obviously needed medical care.

The health insurance companies thus literally get away with murder, with their great lie that they only pay for medical care, they don't decide whether care is or is not provided, and that's because of ERISA. As far as I know, ERISA says nothing of the sort, but legal precedent has interpreted it to provide this shield. And of course, legal precedent by a judge is so much more important than what a law actually says. Or a Constitution for that matter. Meanwhile, the cries of many to amend ERISA to explicitly say what is and is not protected go unheeded. The only instances when the insurance companies have not been able to use ERISA as their shield is when their denial of (payment for) care involves a government employee. You see, like most onerous legislation (the ADA, HIPAA, et cetera), the government exempted itself from ERISA.

The Federal government does not just protect managed care, however. Oh no, It expands it. Just what do you think Medicare and Medicaid are? Let's see, both are programs that contract with "providers" to provide care at a dictated discounted price. Why, that's a PPO! And Medicare Part D? Just another pharmacy benefit management system; just more managed care. It doesn't matter whether the Part D benefit is run by the real managed care industry or the faux one called the government. Managed care is managed care. And it will, it can do nothing but drive up the cost to the consumer. The only other choice for managed care is rationing.

But that's another rant for another time.

Aliens Cause Global Warming and Other Wisdom from Michael Crichton

I had found this speech in PDF format several months ago, and after my last posting decided to look it up and link to it. And I found a couple of other gems to go along with it. All of these are a little long, but they are well worth reading.

The first is entitled "Aliens Cause Global Warming" and discusses the underpinnings of the pseudoscience of anthropogenic global warming.

The second is called "The Case for Skepticism on Global Warming". This goes into a little more detail about some of the problems with the so-called data on which the whole idea of global warming is based. His discussion of the statistical tweaking needed to create the 'hockey stick' graph that we've all grown to hate from Al Gore's "An Inconvenient Truth" is not (as far as I can tell) original to Mr. Crichton, as I have previous seen this same criticism made elsewhere by the head of the American Statistical Association.

The last speech is "Complexity Theory and Environmental Management", which isn't about global warming per se, but does reference it obliquely. It raises some interesting concepts to consider if mankind is going to wade into trying to "manage" the climate of this world when we only have the glimmer of an inkling of a grasp of the edges of what actually drives the climate. (This is beside the point that all 7 billion of us together are too puny to really affect the climate.)

And speaking of Al Gore's ridiculous movie, if you haven't watched it, then don't! Or at least try to do it in a way that keeps money from going to this poor deluded soul. I saw it on Showtime, and I must admit that I was surprised to see certain scenes included in this serious tome on how we are ruining the planet. You know the scenes -- the ones with Al Gore campaigning for president, talking about the death of his sister and the accident that occurred to his son, and finally culminating in the scenes of him losing the election (and yes, the news media's recount of every vote in Florida still showed he lost). I wasn't initially sure what all these scenes had to do with global warming, but then it finally dawned on me -- the inconvenient truth isn't that we're melting the icecaps; it's that Al Gore really did lose in 2000.

I Am Not Postalmed.com!!!

Just got through Googling myself to see if I was having an impact on society yet. It was an ill-conceived notion, and I am now considering prescribing myself antidepressants. But I did find that I am being poached upon.

Many of the links on the Google results page referenced an organization calling itself postalmed.com. ( I left off the www. to keep from creating a hyperlink.) This seems to be some sort of an Internet-based pharmaceutical ordering company that, as best as I could tell from the two or three minutes I spent looking at it, is based somewhere in India.

I am not, and have absolutely no association with, "postalmed.com". Furthermore I discourage all of my readers (yes, all three of you!) from ordering anything from this company. If this company is based in India, then the quality of anything from there is highly suspect. Additionally, India allows its pharmaceutical companies to flaunt international law and copyright/patent law and produce medicines in violation of US and other national patents. Such action contributes to the higher prices we pay for medicines in the USA and should not be rewarded. If it is not in India, it is still not headquartered in the United States and utilizing such a service is a violation of Federal law.

Update on Global Warming

The Canadian National Post continues to expound on the widespread scientific opposition to the idea of anthropogenic global warming. When I first linked to this series of articles, it contained ten articles. The list has now been expanded to 33 articles, with the suggestion that more are to come. Find the current list (and hopefully the ongoing index) here.

If only there were an American media outlet that had the courage to print such a series of articles. But no, like the recent Aug. 13 Newsweek front-cover article (sorry, can't access it online without coughing up money) on the topic, entitled "Global Warming is a Hoax* (with the asterisk leading to a line at the bottom of the cover indicating that the statement was supposed to be a joke), almost all of the coverage in the American media is so pro-global warming it makes me sick. To the writers at Newsweek, let me reiterate: I am a scientist who does not believe in the hypothesis of anthropogenic global warming and I am NOT on the oil industry's payroll.

At least in other countries (which we are being told [erroneously] are more accepting of this fairy tale than we are) the press still sees fit to pursue both sides of an issue to get to the truth. In America, it seems all the so-called journalists have partaken of Al Gore's Kool-Aid.

Is it any wonder that more and more people are getting their news from the Net?