Virestorm-Let the adventure begin

Prologue

September 22, 1918, Vilosplad,  Russia

The gray air filled with the moans of those still alive. The barely surviving were carrying the dead, as they were coughing and wheezing through the rain. The old and the young already gone. Those lucky enough to pass in the early days were buried with respect. Now, large unmarked holes marred the landscape. Filled with the dead in the tattered clothes they ended their lives in. No one left to clean them and dress them. No one left to attend to their final religious rites. The town priest, old and weak before the plague, died soon after the second wave of disease. The third wave though, was the worst. Now they we’re losing the healthy ones. The ones who were supposed to rebuild the community, write about their lives and to remake their future. Just one more blow after a decade mostly filled with war and hate.

Anatoly gazes upon his fellow villagers, or rather, what was left of them and thought “Will there even be one to remember who we were?” The pain felt too great. In the past weeks he had buried his wife, his children, even his grand children. And now he could feel the disease coursing through his own body. And now, even he shakes with fevers, a racking cough, and fatigue. Oh the fatigue. He used to be able to carry two sacks of flour on each shoulder and walk miles. Now, even the weight of his wasted self he can barely carry. No, it can’t be long before it’s his turn for that big hole of hell in the ground. Maybe, if there is something resembling a god, he will be with his lovely Ana once again.

From a hilltop little Ivan watches. No, he won’t go near them. His mother sent him away when she heard about the disease from the next town. She sent him away with bags of barley, dried meat and fruit. She told him not to come down to the village. No matter how loud the people screamed, no matter how much he missed his family and friends. He was to stay away, hide, and she implored him don’t come back until the winter comes. After the ground has frozen it might be safe. “But not a moment sooner.”

Ivan can see an old man shuffle to the graves. He stands over them for a long minute. Swaying to and fro. The rain picks up and its hard to see and then the old man is gone. Ivan turns around and hikes back into the hills, to his makeshift home, to wait for winter to come.

Chapter 1

Spring 2008, Siberia

Two men step out of a black Mercedes sedan. One, very Russian looking. He is heavy, short, thick necked and thick waisted. He scans the horizon with his small dark eyes and permanent scowl. The other man is  tall and very thin. Olive skin and large brown eyes set him apart from the usual visitors here. He is very Middle Eastern looking and very out of place. He walks around to the trunk and removes a heavy sack. He turns to the Russian and with a tilt of his head gestures toward an old man, stoop shouldered in tattered brown clothing. The Russian walks over to the old man and they begin to talk in Russian. They seem to be negotiating. There is some finger pointing. The Russian looks at the old man, angry now. He looks as if he might break him in two. Finally, with a grunt the Russian pulls out a fold of bills. The old man stares at the crisp American dollars as he peals off a few and hands them to the old man. The old man seems wary but gestures them forward.

All three depart the road and hike along a meadow path. The grass is bright green, the meadow erupting in wild flowers. They travel over a hill. Down below is a collection of crumbling buildings. The old man stops. He will not go any further. He points to what is left of the old village. His rheumy eyes look up at the two men. He waits. The Russian reaches into his pocket. He begins to remove his wallet when a loud crack erupts. The old man falls backward with a hole between his eyes and a look of total acceptance. The Middle Eastern man puts his gun away, puts the strap of the sack on his shoulder and begins to hike down the hill toward the abandoned village.

The two men enter the remains of a very old village. The buildings have been abandoned long ago, the roofs caved in and the fences collapsed. They continue down what must have been at one time the main road. The road makes a turn to the right and behind a crumbled fence is a barely visible marker. They begin hiking through brush and bramble over ancient and toppled headstones. Toward the back is a large mound. There is no marker. The Russian turns to the Middle Easterner and nods. The slender man sets down the sack, unzips it and begins pulling out items. He puts on a plastic suit, gloves, mask and goggles. Next he removes a shovel and begins to dig.  The earth is soft now that the frost has melted and the ground is still moist. He digs rapidly through the soft earth and then the ground becomes hard again. He has reached the layer where the frost never melts. He pulls out a pick and swings at the ground to loosen the earth. Hard clumps come up and after toiling for a little while he starts to see shreds of gray and brown cloth. He slows his pace and begins to pick at the earth with finer tools. Soon he has uncovered two bodies one lying across the other. He gets very serious now. He carefully removes the clothing from the torso of a man. He gently cleans the soil away.

For Ahmed knows that great respect must be paid to the dead. Even the infidels are to be treated with respect, even those abandoned and mistreated by their own. He turns to the East and makes a nearly silent prayer before resuming his task. He removes a scalpel and makes an incision on the dead man’s right side. He cuts through the rib cage and inserts a device to spread the ribs. Next he reaches into his sack and removes a thermos looking container. He opens the container by releasing two latches and inside is a second container with a screw top.

Next he changes his gloves and dons two layers. He reaches into the chest and feels the hard frozen lung tissue. Perfect, he thinks to himself. He removes a new knife with a long serrated edge and cuts into the tissue. He is able to remove a piece the size of a tennis ball. He looks at it in the light and can see that the dark brown tissue is filled with a thick frozen yellow liquid. He carefully quarters the flesh and places it in the container. He screws the cap on and applies an adhesive tape around the lid. Next he washes the receptacle down with pure alcohol. Again he changes his gloves. He then places the container into its parent and seals the latches. He reaches into his bag and removes an object that looks like a squat cylinder with a thread top. He screws this into the thermos and twists a valve. A hiss is emitted and the exterior of the thermos quickly frosts over. He puts on a pair of insulated gloves and places this into a collapsible insulated bag that he removed from the sack. Next he gently places a white sheet over the body and says a prayer for Allah to accept the soul of this infidel for the sacrifice he has made for the nation of G-d.

He then covers the bodies with the dirt. When he is done he removes his protective gear. He asks the Russian to turn away and he then removes his clothing. He puts all of this in a pile and soaks it with lighter fluid and ignites it. When the fires is out and he has put on fresh clothes he lays down a prayer mat and facing East prays thanks to Allah for this great day.

The men hike back to the Mercedes and depart.

Slaying the beast

In my last article I introduced you to "the hidden beast" in health care which is the fact that we lack enough physicians in our country to handle our growing and aging population. I may be a bit pretentious in claiming that I have ideas on how to slay the beast but I do have some very specific ideas. These ideas will require patients, physicians and the various insurance companies to undergo a dramatic shift in how we interact.

First, we must accept that there is no way we can create enough healthcare providers to meet our upcoming demands. How do I know this? Training a physician takes approximately twelve years after high school on average. If we start today, and we should, encouraging kids in junior high and high school to begin thinking about medicine and mentoring them through the education process and simultaneously expanding medical school enrollment to allow for this influx, under the best of circumstances we will begin to bring these young doctors to you in 2025. Now, these kids are pretty bright and I think they probably read the same articles I do that Medicare will go bankrupt somewhere around 2018. I wonder how many of them are interested in being professional physician volunteers. By the way, they will probably owe somewhere in the neighborhood of $500,000 for this privilege.

Ok, so that idea may not work. Well, we could just make the existing doctors work harder. We can continue dropping reimbursements so they will be incentivized to work harder and see more patients. Oh, wait, that's what Medicare has been doing for the last 10 years and it hasn't worked. On top of this, I hear patients everyday complaining their doctor has no time for them and how can an office visit last only five to ten minutes. I guess people might be even more disappointed if the visit lasted one to three.

Perhaps we need to think a little "outside the box". I suggest we try to make our doctors more efficient and incentivize this efficiency. For example, attorneys, accountants, and countless other professionals are compensated for services that are not face to face. Did you know that insurance companies have created reimbursement codes for a doctors phone calls or emails to a patient? But, here's the zinger, they pay zero dollars for this service. Every physician deals with this issue differently. The majority will not provide any significant treatment or planning over the phone or by email but rather require face to face contact. Many will notify patients of lab results and x-rays by phone, or at least have their office staff do it. Some will require a return appointment to discuss results. I suspect it really depends on how busy they are.

Furthermore, the forward thinking members of our congress created the Health Information Portability and Accounting Act of 1996, better known as HIPAA. Part of this legislation prevents your doctor from emailing you if either email company does not use encrypted secure servers. If your medical information makes it into the wrong hands the fines for your doctor can be tens of thousands of dollars. I suspect this may represent a bit of a disincentive to your doctor as well.

I suggest that compensation for non face to face care be established and that the government "encourage" email companies such as Google and Hotmail to have special servers that are for the delicate transfer of this information. Just by enabling me to email a patient that his x-ray was fine would be a huge improvement in efficiency.

Now let's get a little bit controversial. Many of you are thinking what about a greater use of physician's assistants (PA's) and nurse practitioners (NPs)? I think that this is a great idea, but, we have to recognize the skill levels that each of us has. PA's and NPs typically have two years of training beyond their undergraduate degree. They are very well suited to managing routine health issues including annual check ups, uncomplicated diabetes and hypertension care, treatment of routine respiratory infections, etc.. Unfortunately, many doctors use these vital assistants as substitute physicians and place responsibilities on them that are inconsistent with their experience and training. On the other hand, I think that it is a terrible waste of resources to use highly trained physician's to do these activities.

In fact, I find it ironic that over the last twenty years there has been a huge push for physicians to become primary care providers. We are taking our best and brightest and encouraging them to focus on the least complex care. In fact, if your doctor sees you for five minutes to tell you that you have a viral upper respiratory infection he is paid practically the same amount  as if you come in coughing, and wheezing with pneumonia. Yet the two situations result in a very different amount of complexity and time required.

I would suggest we establish clear expectations on patients with appropriate incentives in the way of copays and deductibles that pushes them toward PA's and NPs for routine care and incentivizes the doctor to pick up the most complex patients they can. In fact, I suggest that we push more of our doctors to specialize. There is far too much information for someone to handle in a general way. When I was in medical school there were about five commonly used blood pressure medications. Now there are twenty categories each having dozens of medications. In fact, many doctors trained in primary care fields have left their practices to become hospitalists. Hospitalists get to focus on hospitalized patients, i.e. those that are the most ill, because the care is rewarding, the hours are structured, and once cured the patients return to their original practitioner. This model could be expanded with a far better structure for reimbursements.

In the ideal world easy routine care could be provided by a PA or NP. Those who don't respond would see a physician and in some situations one who has specialized in the area of concern and get placed on appropriate care. Once cured or on a treatment plan the patient would then return to their original caregiver, freeing up the physician/specialist to move on to the next complicated case. In addition, the PA or NP would have lower level assistants reporting to them who routinely communicate with patients to make sure that they are taking their medications as well as setting up even lower level visits for just checks on those issues that need chronic monitoring.

The entire health care system would be changed from it's current design which is flat and wide to a pyramid with the doctor at the top and all of the other caregivers below. By doing this we could successfully do more with less. And, I suspect, we may even save a few dollars. I know that what I suggest is radically different from what we are used to. In fact, some people may feel offended at my assessment. But, that is why I have established this blog. I encourage anyone to help come up with better ideas. And perhaps if we are very lucky we can help change this situation.

Best of luck to us all in slaying the beast!

Return on Wednesday and I will post the first chapter of "Virestorm". I am hoping to provide an interactive entertaining way to share a story that I have been working on in pieces for the past year. I will use your input to help steer the characters and action to a hopefully exciting finale.

The hidden beast

Watching and listening to the news lately one would think that all of the troubles in healthcare can be solved either by having everyone purchase insurance coverage or finding a funding source and giving it to them. I find it remarkable that the most "brilliant" economists keep on missing one of the most important factors in health care delivery. Who is going to provide the care to all of the newly expanded health care rolls? They somehow have the mistaken belief that if one has a health insurance card all will be well.

Unfortunately, they have forgotten one very important factor. While our population ages and shifts into a larger and larger number of people who require ever greater care we have not had any significant growth in physicians in decades. There was a bump in medical school enrollment in the 80's but that group, which I am part of, is established and unlikely to significantly increase it's workload.

For the past 20 years the best and brightest have chosen fields like investment banking and computer engineering. These fields have had dramatically greater compensation growth. In fact in the past 10 years physician compensation has had virtually zero increase so relative to inflation the income has gone backwards. This insight has not been lost on the young men and women in college. So, while our population grows our number of graduating medical professionals are hardly keeping up.

I predict that in the next 3 to 5 years this issue will hit a break point. Those with an existing physician will start off doing fine but if you don't have a doctor caring for you it may be near impossible to find one. This has already started happening in the primary care fields but it will extend to specialty care as well. In addition, there is a large number of doctors 60 to 70 years old who have delayed retirement the last 5 years. But, as the economy rebounds the doctors who are near retirement will see their retirement investments grow and become large enough to allow them to retire. This will put a further strain on an already highly stressed system.

In fact, as this group of doctors goes in to retirement a large number of people will be looking to establish relationships with new physicians. But they will be in direct competition with a younger group of the aging population as well as newly insured. I predict that this will create a very interesting dynamic that hasn't occurred in the country in generations. We won't need to worry about death panels or insurance denials of care because a large number of people won't be able to make it into an office.

In fact, we will see a huge shift to using the emergency room as a site of primary care. This has already occurred for the uninsured and under insured population but this will become typical for most everyone. I predict that insurance companies will begin to aggressively recruit doctors to their panels. They will require exclusive agreements and will give special packages to the doctors to recruit them in. This will likely shift another segment of the population into the ER. These will be patients who no longer can see their doctor because he is a provider for only a finite number of insurances.

The state and federal governments will be faced with an unprecedented issue. How to provide care for literally millions of people. We might look to recruiting doctors from overseas but as the economies in Asia begin to grow I suspect the doctors will sense opportunities for success in their homelands and will choose to avoid the chaos here.

Is there an answer? I doubt that there will be any easy way to solve this but I will begin to offer some ideas in my next blog "Slaying the Beast".

Time to share

Today begins my journey to share with you my thoughts and feelings about health and healthcare and how it relates to each and every one of us. For several years I have had patients, friends and family ask about my opinion regarding health policies and health care. Often times they are scared about something they read in the newspaper or heard on the radio or television. I'm not surprised about the fear and confusion since most of what is presented is slanted in one angle or another.

In fact, more than once a patient has turned to me with tears in their eyes and asked what will happen to their insurance or whether I will be available to help them after new changes occur. Usually, these are the moments I slow everything down and take the time to explain from my perspective how I think events will play out. Each time this happens I wonder how many others are out there scared and confused and wanting an answer from someone they trust who is impartial and understanding.

So that leads to why I am writing this post today and why I am going to continue doing this into the future. My plan is to make commentaries about various aspects of what is occurring in both the macro national and world environment as well as the micro personal environment of myself. I hope to relate to my readers and to share stories and anecdotes about success as well as some of the scariest and even strangest moments I have experienced.

Each time you look at one of my new posts I hope to share with you a new idea or thought. I hope that if my comments move you that you will share that with me. I also look forward to you asking questions for me to ponder and answer. Together I hope we can all grow and learn together.