Jerry Pogue, a Los Angeles managed care consultant quoted in the July issue of Northern California Medicine, may have the answer as to why physicians let themselves be completely deprofessionalized by accepting capitation. He calls capitation the “cocaine of managed care,” noting three levels of capitation addiction: a capitation revenue of 10-15 percent gives physicians a “rush” twice each month when the capitation payment arrives; a capitation revenue of 20-30 percent is enough of a “hook” to put physicians into a dependency relationship with the payor; a capitation revenue of 45-55 percent is akin to “mainlining” by addicts. At this point, a physician changes his behavior to the required efficiency and control of excess utilization. . . In other words, we are then enslaved agents of the carrier and have minimal responsibility to our patients. They are only the commodity providing us our fix twice a month. . . Anybody out there for moving forward into our previous state as a cottage industry with patients making their decisions based on our explanation of the risk/benefit and cost/benefit analysis?

An ENT surgeon asked, as he was pulling out a wax plug, “Do you wash your ears out in the shower and then blow-dry the ear canals?” Well, it works. Dried wax falls out during the course of the day and no plugs recur. Can you believe the multiple uses of this appliance? The hair dresser says to blow-dry your hair. The ENT surgeon says to blow-dry your ears. The proctologist says to blow-dry your hemorrhoids. The urologist says to blow-dry the prepuce. The gynecologist says to blow-dry under the mammary glands. The dermatologist says blow-dry under all skin folds. The foot doctor says to blow-dry between your toes! How did we ever get dressed in the morning before the blow-dryer was invented?

The Sacramento Union reports that many Canadians travel to the US for their health care. The same can be said for almost every country in the world. . . Has anyone ever heard of an American journeying to a foreign country for anything other than alternative health care and arcane procedures that would never gain FDA approval?

The Sacramento Bee reports that the Democratic Senatorial Campaign Committee is urging health-industry lobbyists and executives to pay $5,000 to attend an “issues forum” featuring Clinton administration officials who will make crucial decisions on health care reform. The purpose cited is “to fatten its political war chests,” (at our patients’ expense). Isn’t that more reprehensible behavior than physicians accepting medical and drug information over a meal, or accepting a patient starter sample from a drug rep? . . .Or is that a sign of the times that we are all too busy looking into each other’s lives, we don’t ever look into our own to clean it up?

In US News’ annual rankings of the Best Hospitals using 16 specialties, Johns Hopkins and Mayo were joined by three California institutions (UCLA, UCSF and Stanford) in the top 15. UCD made the list, not only in orthopedics, cardiology and cancer, but also in rheumatology, endocrinology, neurology, urology, and gynecology. Hats off to our Professors. Of interest was that the NIH in Bethesda, with all its tax dollars, only made the list in four specialties.

Scientific American (7/93, p.109) is joining the health care debate: HMOs offering to meet all of a consumer’s medical needs for a fixed fee create a set of perverse incentives for physicians and patients. Doctors do best financially by offering as little care as possible; patients have paid up front and so profit by insisting on maximum treatment. The HMO has an incentive to sign up a maximum of subscribers and to minimize the time spent with a physician.

Not to be outdone, Playboy offers the following, from Peter Moore, who sees four levels of bureaucracy between him and his doctors. After a consultation with his doctor came the seven most expensive words in medicine: “But we better run a few tests.” When he met his deductible, he “hit pay dirt–100% payback. That’s when the dollars ceased to be real. Somebody else was picking up the tab. When I pay for health care in fake dollars, I pay no attention to the charges.” About the Canadian system, he says, “Canada, shmanada. The entire country – 26 millions souls – could fit on the pinkie toenail of the U.S. health giant. . . How ironic it would be if, at the very moment when individual freedom of choice is sweeping the world, the republic that started it all tried to solve its biggest problem by embracing what could become the world’s biggest bureaucracy. . . It costs a lot to feed bureaucracies, which are to American society what ticks are to dogs.”

Did you know Americans spend more on their hair than on medical research?

The Harvard School of Public Health study reports that 84 percent of heart patients who sought a second opinion prior to a coronary artery bypass graft were told they didn’t need the surgery. Responding to my comments last month about CABG in a 91-year-old patient, a colleague mentioned that “in our training we always worked up a patient until he either died or got well.” Perhaps that is the nature of university training programs. But there was a corrective influence when we went into practice. We had to convince our patients to spend money on the procedures and tests we advised. This was true even in the early days of Medicare when we asked patients to pay us and they collected from the government. Now with payment in fake dollars, there are no brakes on the system. With physicians’ practices getting 19 percent of the health care dollar, (8 percent to physicians if we exclude a 60 percent overhead), isn’t the current preoccupation in reducing our income by 5 percent here and there rather like mopping up the water on the deck of the sinking Titanic?

During a presentation to one of our staffs, a neurologist stated that there are 14 million Americans who have or will have Alzheimer’s. The current annual cost is $60 billion. If each had a PET scan at the going rate of $2200, there would be a 50 percent increase in the national costs to $90 billion in just one disease with one test that would not affect outcome. I’m sure there would be another 14 million Americans who would try to convince their doctors that one of their parents needed a PET brain scan. There is no managed care program that could stop such a stampede.

Just In: A patient was seen three months ago for routine quarterly pulmonary evaluation. He stated that his wife’s multiple sclerosis had gotten worse and she lost her job and insurance. He now only had Medicare and no drug coverage. He had gone to his pharmacist and the drug bill paid by Managed Care Systems would cost him over $600 a month. He asked for new prescriptions using the lowest cost medications possible. Alternate prescriptions were written for his cost/benefit evaluation. He was now happy to announce that he had gotten his monthly drug bill down to slightly over $200 with no lost efficacy. (SSKI was 1/8 the cost of the competitor, Theochron was half the cost of it’s competitor…) The point not to be missed is that managed care, which has only one reason for existence, namely to reduced costs, was still three times more expensive than patient responsibility when the patient was at financial risk.