A Modest Health Care Reform Proposal

Most of me thinks that two health care reform options are most worthy:
1. Consumer-paid fee-for service with a spartan government-provided safety net for the poor. OR
2. A single-payer system.

But I met a primary care physician involved in health care reform planning whose views represent a more middle-of-the-road approach that seems a good balance between concern with quality and cost. So I invited him to summarize his key recommendations in 500 words and that if I thought the document was worth your reading, I'd post it.

Here it is. As always, comments are welcome.

Health Care Reform: Viewpoint from a Primary Care Perspective
by Michael Rosenblum, M.D.

There are three essential issues for health care reform in the United States

1) We need a uniform national digital health record--Many errors are made due to illegible handwritten entries in patient records.A majority of prescriptions are still written by hand, and a majority of outpatient medical records are written by hand. We could greatly improve the quality of care, and save a considerable amount of money, by having national standards for digital data entry and making all health care records accessible from any point of care in the nation. There are political barriers to instituting this policy. Proprietary electronic systems would have to yield to uniform national standards. There are concerns about the privacy of patient records. We need to overcome such obstacles and get health care into the digital age.

2) We need to re-emphasize primary care—In the United States we are culturally addicted to the latest technological advances. We spend a disproportionate amount of the health care dollar on the latest laser surgery and the latest high-tech drugs. To provide health care to all citizens, we need to train more primary care doctors like pediatricians and internists and family doctors. The importance of the primary care doctor in providing preventative care, and coordinating the patient’s journey through a complex system, cannot be overemphasized. Insurance reimbursement needs to be increased for primary care, and decreased for specialists if we are to achieve this goal.

3) We need to fix Medicare and Medicaid before establishing costly new federal programs—The Medicare “trust fund” is on the verge of insolvency. Medicaid (MediCal in California) reimburses doctors and hospitals typically at 20-30% of the current market rate, resulting in poor access for patients. Both of these programs need to repaired and reinvigorated. Fortunately, this can be achieved without creating vast new federal agencies and hiring hundreds of thousands of new federal employees, as would be needed for the new programs proposed by the administration and Congress. The infrastructure for these programs has been in place since the 1960s. We merely need to fund them and they can reach their full potential. For example, Medicaid could be made available to uninsured adults up with incomes up to 400% of the Federal Poverty Level, rather than the current 125%, to make a large proportion of currently uninsured adults eligible. There are huge political barriers to reforming Medicaid. For example, Medicaid uses a formulary of generic drugs, and there would be strong opposition from the pharmaceutical industry to increasing funding for this program. Funding for Medicaid is partly from the states, and they are pushing back on any increase in the program that would require them to fund more health care. Clearly, the federal government will have to shoulder the fiscal burden of Medicaid expansion, but this is cheap by comparison to setting up a whole new program.

How to Not Procrastinate a Big Project

It's tough to determine how long a big project will take. So waiting until the last minute greatly increases the risk it will be done poorly.

THE KEY: Make this rule inviolate: I will start a big project the hour or at least the day it is assigned to me. If I don't know how to get started (for example, how to structure the project,) I'll get help immediately.

How to motivate yourself to stick with that rule? Remind yourself that if you get started right away, the project will be more FUN:

• You'll avoid the stress of trying to get it done well at the last minute.
• You'll have time to play with the parts of it you enjoy, for example, wordsmithing or illustrating it.
• If you're done early, you'll have gotten yourself a chunk of time that you can enjoy without the project hanging over your head.
• You'll likely have done a better job, which will yield more praise and make you proud of yourself.

A Permanent Solution to the Down Economy

The government cannot permanently spend our way out of recession. Its so-called investments will, on average, lose money. Otherwise, the private sector would have funded them. And such investments are, on average, unlikely to kick-start the private economy to the extent necessary to replace our tax dollars.

So eventually the tax dollars needed to fund those government schemes will run out and the government will have to stop the programs or print more money, reducing the value of our savings.

The long-term answer: Create a nation of ethical entrepreneurs: people who know how to identify unmet needs (for example, in-home companions for shut-ins) and develop and execute an ethical business plan for meeting that need.

That would not only improve society, it would increase the chances of millions more Americans, especially the not-academically-oriented, to make a good living. Today, so many such people struggle to pay the rent, spend so much time looking for their next job and after landing one, living in fear of getting laid off because of a personality dispute, it's a project job with a built-in end date, or that their job will be shipped to a low-cost country. Instead, a nation of entrepreneurs will be hiring themselves as their own business's CEO.

How to create a nation of entrepreneurs? From kindergarten through college, the curriculum should include hands-on opportunities to learn ethical entrepreneurialism. How would that fit into the school day? Lengthen the school day and school year, which brings the additional advantage of ameliorating the nation's child care problem. Also, pare elements of the existing curriculum that are less important than entrepreneurship. Does anyone want to defend that, for example, it's more important that all students know geometric theorems than learn entrepreneurship? How about understanding Shakespeare's arcana? The intricacies of the periodic table of chemical elements? How about all those wars from the Peloponnesian to the War of the Roses? The endless celebration of multiculturalism suffused throughout today's curriculum?

What do you think?

Are You Lazy?

Do you think you're lazy? If so, do you think you've paid much of a price for it?

When I think back on my 3,000+ career counseling clients and my successful and not successful friends and colleagues, it's clear to me that the #1 factor in success is focused drive: the willingness to work hard and be focused, not dabble around.

Whether in trying to land a job or succeed in one, unlike in Hollywood portrayals, the hard worker usually prevails. Of course, sometimes despite hard work, one fails, but focused drive usually is necessary.

For example, when I give talks to unemployed people and ask them to raise their hand if they're a procrastinator, 80 to 90% do. When I ask the same question of a group of successful people, for example, executives or college presidents, only 10-20% do.

So if you're a procrastinator or blame your laziness on therapist-concocted excuses like "fear of failure," "fear of rejection, "fear of success," or that you've been mistreated as a child or adult, I implore you to force yourself to prioritize work: Be aware of the moment of truth when you're deciding, usually unconsciously, whether you're going to work or play, whether you're going to dabble in something new yet again or have the discipline to become an expert in something.

If you're not motivated to work hard by the need for money or status, perhaps you'll be motivated by this: I've found, over those 3,000 clients and countless colleagues and friends, that, especially among bright people, the people who are most content with their lives, who feel they've lived the life well-led, are usually not people who have prioritized fun or family over work. They are people who work hard and focused so they can become to be the go-to guy or go-to women in their career--whether it's clerk or CEO.

Today You Start Keeping What You Earn (It's Cost-of-Government Day)

Did you know that you worked for the government from Jan 1 to today, Aug 12 (224 days) to pay all the taxes, fees, and regulatory burdens the govt. imposes on you?

In other words, in 2009, the cost of government consumes 61.34 percent of national income, by far the highest percentage since this figure has been calculated. (See the chart.) HERE's the link to the report, which includes the calculations.

And remember that President Obama's big-government schemes are just now getting enacted.

Curing YOUR Procrastination

What's the reason(s) you procrastinate?

Hedonism. Some people feel they have the right to always choose more pleasurable over less pleasurable experiences. Solution: Realize that your life's worth is what you've produced. That's true whether you're a dishwasher or a doctor.That often requires choosing less pleasant tasks.

Fear of failure: Many people know, from previous experience, they'll find tasks odious and will often do them poorly. Solutions: Get a less demanding job, exchange tasks with a coworker, get help on projects, get training, avoid perfectionism--especially on first drafts.

Dependency: Whether you're a trust fund baby, welfare or unemployment recipient, stay-at-home-parent, or have parents who'll always bail you out, dependency can demotivate you. Solutions: Fend for yourself--give away your money if necessary. And remind yourself that you don't want to be a parasite on this earth: you are worthy to the extent only that you've been productive, having had a positive impact on those around you globally and/or locally.

External locus of control: You place too much responsibility for your success on external forces, for example, God, racism, or spirituality ("the universe will provide" and similar nonsense.) Solution: Yes, not everything is in your control--luck plays a role--but success lies mainly within you, sometimes with assistance from others you trust.

Lack of drive: Some people are lucky enough to be born with high drive, others not. Solutions: If you're not, it may help to find a partner or a cause you deeply believe in. Sometimes, having a spouse and/or a child can add drive.

Should Students Sue their College?

A woman filed an lawsuit against her alma mater for not providing enough career services. That may have been frivolous but millions of college students, in my non-lawyer opinion, have enormous justification for suing their college:

• Failure to disclose. Colleges, for example, hide their obscenely low graduation rates. For example, the four-year graduation rate for full-time freshmen at the 20-campus California State University system, which enrolls nearly a half million students, is only 17%, 40% in five years, 49% in six years. Only a tiny percentage of applicants have been informed of their odds. Such statistics if they appear at all on a college's website are buried in a place that few students find. And college recruiters too rarely mention non-self-serving statistics. If all prospective students were informed, no doubt many fewer would attend.

When a person buys a home, the seller is required to disclose all the home's actual and potential problems or face a lawsuit. A potential investor must be informed of the risks or can sue. I predict that a successful lawsuit could be filed against a college on grounds that it failed both in admitting students it knew were unlikely to succeed and in not disclosing that to them.

In my view, all colleges should be required to prominently post on their website and recruitment brochure its four-, five-, and six-year graduation rate for students with varying high school records.

• Failure to perform. Nationally, college freshman-to-graduation growth in reading, writing, critical thinking, quantitative reasoning, etc. is frighteningly low. A study funded by the Pew Charitable Trusts found that 50 percent of college seniors failed a test that required them to do such basic tasks as interpret a table about exercise and blood pressure, understand the arguments of newspaper editorials, or compare credit card offers. Almost 20 percent of seniors had only basic quantitative skills. For example, the students could not estimate if their car had enough gas to get to the gas station. Unbelievably, according to the U.S. Department of Education's most recent Higher Education Commission Report (the Spellings Report,) things are getting even worse: "Over the past decade, literacy among college graduates has actually declined." According to the most recent National Assessment of Adult Literacy, for instance, the percentage of college graduates deemed proficient in prose literacy has actually declined from 40 to 31 percent in the past decade. Employers report repeatedly that many new graduates they hire are not prepared to work, lacking the critical thinking, writing and problem-solving skills needed in today's workplaces."
  

I predict that a successful lawsuit could be filed on grounds that a college failed to perform. If someone bought a $100,000 car that wouldn't work, he'd demand the dealer fix it, refund the money, or would sue and easily win. Yet colleges too often take $100,000+, years of a student's life, and provide an education that doesn't work. Such students would seem to have a winning lawsuit.

• Deceptive advertising. College recruitment materials (brochures, websites, etc) too often manipulate prospective students into believing that if they graduate, they have a solid chance of being well employed in careers related to their major, even in such long-shot majors as art, music, and journalism. For example, many colleges' recruitment materials profile (complete with color photos) successful graduates. That's often true even when a college knows that most of its graduates (not the mention the non-graduates) will never earn enough money from such majors to even pay back their student loans, let alone earn a middle-class income from art, journalism, music, etc. I believe that a lawsuit claiming deceptive advertising could prevail.

Yet people don't sue colleges (or schools) because we've been conditioned to be in awe of our colleges and not to search for what's behind their ivy-covered veneer. Colleges have powerful marketing and lobbying machines that manipulate the media and government into deflecting attention from what colleges are really like by trumpeting misleading claims like "College graduates earn a million dollars more" and "America's higher education is the finest in the world."

Wake up. Higher education is among the largest purchases and certainly the most time-consuming purchase you'll ever make. Alas, too often it yields a poor return for the time and money invested. Make that purchase at least as carefully as you would a car.

And if you're unhappy with the education you've bought, do what you'd do if your new car was a lemon: demand it be fixed or that you get your money back, and if the college fails to do so, consider suing its Ivy-covered butt.