Oregon has had government involved in health care for quite a few years.  The state electorate also approved the concept of state sanctioned suicide several years ago.

Recently, the board that reviews the medications that are approved for state residents made a determination that was controversial...in my mind if no where else.  The board, in essence, said that, given the cost of a certain medication, it would approve suicide for this patient but would not approve use of the medicine given its relative newness and the lack of convincing data as to the outcome.  It had essentially set a price on the human life involved.

Today I read the story concerning Denver Children's Hospital and heart transplants in infants that use the heart from another infant that died a 'cardiac-related death'.  This differs from a heart harvested from a brain-dead infant in which that heart is beating until removed from the donor body.  A decision has been made that the donor that has been pronounced dead and has been in that state for only 75 seconds, is a valid heart donor for purposes of this new program.  The earlier line that had existed required death be determined only after some five minutes during which time the heart did not re-start itself.  In this instance, the length of time a person had been deemed 'dead' had been reduced to assure that the harvested heart had a decent chance of functioning in the new body.  The three cases in which this approach has been employed resulted in three infants alive today.  The decisions to withdraw life support were made by the parents in all three instances.

We know so much more today than we did a decade ago.  We can do things from a medical perspective that were impossible then, and these procedures have become commonplace now.  We are, in this area, pushing the envelope as it has never before been pushed.

I know there are at least two sides to these issues.  I have good friends whose daughter lives today because of transplanted organs that were available on a timely basis.  I can't even begin to comprehend being placed in the middle of such decisions, and I earnestly hope that never befalls me.

And this leads to my general question:  Is there a line we dare not cross?  If so, where is or was that line?  Am I comfortable with an appointed board making life and death decisions about me?  Who among us can claim the right to make such a decision?  How do medical ethicists deal with these kinds of issues?

I don't profess to have the answers to these questions.  If you do, and you're willing to share, I'd appreciate your comments.

I've written about the consolidation of local health care organizations over the past months.  In preparing for a talk I delivered to an insurance agent's organization last month, I dug a little deeper to see what the trends seemed to be for the future.

There are some very interesting things happening to and with health care delivery and these things are, in part, already on or affecting the local scene.

Retail Medicine...

Several major corporations have experimented with and made commitments to what I'll call 'retail medicine'.  Major drug store chains have had walk-in clinics in their stores, and have gotten so serious about it that they've actually purchased the companies that were supplying the services.  One of those is Walgreen's and we see the result in Germantown.  Our local Walgreen store is 1 of 13 in Wisconsin with in-store clinics and that number is expected to be as high as 19 by the end of 2008.

Wal-Mart is doing similar development across the country along with the CVS drug store chain and several others.  These models all tend to rely upon the Nurse Practitioner and work to establish referral relationships to local physicians for the more serious conditions encountered.  Costs, according to the Take Care Health Systems (Walgreen) website range from $59 to $74 per visit with additional fees charged for vaccinations (seasonal flu shot priced at $24.99).

Physician Shortages... 

There are serious shortages of physicians in America and that is, in part, prompting the 'retail medicine' movement discussed above.  Massachusetts learned this the hard way when it passed laws that required virtually all citizens to have health insurance.  There were simply too few primary care doctors available in the state to handle the new demand that had been created.  The physicians who are moving through the education system today are too often choosing specialties that pay more and that have better schedules so they can also spend time with their families and pay off their loans more quickly.

These shortages are prompting our medical colleges to step up the effort to cause more graduating physicians to opt for primary care service but this will take time and there will need to be some economic push to make it happen.  This is spawning the following effort.

Nurse Doctors...

Minnesota has graduated at least one class of Nurse Doctors who are entering practice across that state.  This is a doctorate level program that claims to produce practitioners that "can do almost everything" a primary care physician can do except for some surgical procedures.  This program is being expanded to be able to graduate more Nurse Doctors every year as the program ramps up.

As we can all understand, the physicians' organizations are not at all happy about this movement.

Dentist Shortages...

The average age of dentists in many states, Wisconsin included, is increasing at an alarming pace and we are beginning to see a shortage of dentists.  Minnesota again seems to have taken a lead position with legislation that was being considered which would permit Dental Hygienists to both drill and extract teeth in addition to their normal responsibilities.

As you would also expect in this situation, this is meeting strong resistance from the organizations representing dentists, but the simple fact that this found its way to the floor of the Minnesota legislature is significant.  Minnesota has been more prone to experimentation in the general area of health care (health maintenance organizations took off very rapidly in this state in the early-1970s), so these trends aren't all that surprising in our neighbor state.

Summary...

Our health care world is changing very rapidly.  If we were to become a Rip Van Winkle and sleep for even just ten years, we'd likely encounter a strange new health care world when we awoke.

Who can say what is good or not good in these regards.  Time will tell which, if any, of these initiatives we will have accepted and which we will have discarded as bad ideas whose time hadn't yet arrived.  Some way needs be found that will permit us to control costs.  If we rely upon government to do that, I'm afraid that the consequences will be heavy-handed control and rationing of services...and I cannot find it within myself to think that is an improvement.

Have you ever heard of Progressive Healthcare?  No one else had either until the press release today announcing the achievement of a joint operating agreement between Columbia St. Mary's and Froedtert & Community Health.  Progressive Health will "financially integrate, govern and lead" Columbia St. Mary's and Froedtert & Community Health.

The new entity will have co-Presidents, Leo Brideau of Columbia St. Mary's and Bill Petasnick of Froedtert & Community Health.  (I don't recall too many co-Presidencies working out for any length of time.  Maybe this is simply part of the transition plan.)  The agreement is to be finalized in 2008.  (This provides a lengthy window which might indicate that there are some nitty-gritty issues yet to be handled.)

This will create a large, multi-faceted organization.  The combination will include Columbia St. Mary's Hospitals in Milwaukee, Ozaukee County, the Sacred Heart Rehabilitation Institute, 30 primary care clinics, the Columbia School of Nursing and a partnership with the Orthopaedic Hospital of Wisconsin on the one side, and Froedtert Hospital, Community Memorial Hospital in Menomonee Falls, and the relationship with the Medical College of Wisconsin on the other.

It is only reasonable to expect that consolidation will cost some jobs since duplication has to exist, add other jobs due to new skill sets required and generally shake up what has been the status quo.

The chairman of Progressive Health, James Wigdale, chairman emeritus of the Marshall and Ilsley Corporation stated, "I firmly believe Progressive Health will offer consumers a better choice, providing the highest quality care at the lowest cost while fulfilling our commitment to be good stewards of the community's resources."  (That is a pretty heavy goal.  Highest quality and lowest cost are seldom seen together.)

Are we done with puzzle pieces so far as our healthcare community?  Hardly likely.  Remember that Synergy still has its decision to announce in the next couple of weeks.  Only time will tell the story of consolidation's benefit to the community.  Healthcare consolidation and building booms have almost always caused overall costs to rise as competition stiffens.  If Progressive Health has found the formula to cause that to be reversed, then this may prove to have been a most significant announcement.

Consider, also, the many subordinate relationships that will now be impacted.  Vendors to one group may win over vendors to the other group.  Network relationships with insurers and administrators may be impacted, too.  Software issues will abound.  The shadow cast by this announcement is large even though invisible to most of us.

The footprint of healthcare continues to be changed throughout Southeast Wisconsin.  For the better or the worse is yet to be determined.

Seemingly everytime we pick up a newspaper or periodical we see that health care costs have risen again.  The only real question anymore is 'How Much?'.  Of course, if we still have health insurance, the premium rates continue to go up and up.  What in the world can we do about this?  Would statewide mandatory insurance coverage do the trick?  Can we somehow legislate lower insurance premiums?  Are the drug companies really the culprits?  Maybe we simply need to move to Canada or Europe.

Recent studies show that our national health care spending increased in 2006 by 6.7% to $2.1 trillion.  That means that one out of every six dollars spent in our national economy goes for health care.  The 'good news' in this staggering number is that this is actually slower growth than we saw for 2005.  Apparently we're going in the right direction, even if too slowly.

Another amazing fact, to me at least, is the amount of 'out-of-pocket' spending each of us averages after insurance premiums, etc.  In 2006, we spent, on average, 12% out-of-pocket for our health care expenses.  Know what we spent out-of-pocket in 1960?  We spent 47% out-of-pocket for health care expenses. 

That means that we are shielded to a much greater degree today from our real health care costs than we were in 1960.  Our out-of-pocket costs have decreased steadily since 1960.  We are often at the point today where we think of the cost of health care as being the $10 or $20 co-pay we have to come up with when we go to see the doctor.  Or, the $20 or $30 dollars we have to cough up for medicines.  Those amounts are very small percentages of the total costs.

Why is this important?  It is important because we need to think about what we're spending if we're ever going to be able to bring this cost spiral under control.  If we come to understand that the real cost of the doctor visit is in the range of $125 to $150 or more, we can begin to understand that maybe we shouldn't be running to the doctor everytime we have a runny nose or a cough.

Another very interesting fact is this:  more than 50% of all health care claims costs in America today are to cover lifestyle-related illnesses.  Those are the things that you and I can control to one degree or another.  But, we can't control them if we don't know about it or if we choose not to do anything about it.  What are 'lifestyle' issues?  Smoking, alcohol use, obesity and simply laying around doing no exercise.

Does this apply to us?  Here are the most current facts:  One in every four Americans eat fast food every day!  Six of ten Americans do not exercise or seldom exercise!  Two of every three Americans are classified as either overweight or obese!

This is the real source of our health care cost crisis.  We have met the enemy and it is us!

No mandatory state programs, or profit controls on drug companies or anything else is going to solve this problem.  The simple truth is that this is up to us.  All the rest of these proposals are simply pablum calculated to make us feel good.

That is why this 'stuff' is flowing from the mouths of politicans.  And it does nothing to solve the problem!

Let your politicians know that you understand this.  If they really want to help us, they'll begin an educational program using some of the 'smoker money' to get the true message out.  And, be sure to tell them we do not want laws banning fast food or drinking or smoking.  We need to take responsibility for ourselves.  No one else can do that for us.  The marketplace will make its own corrections just as you've begun to see with the menu changes going on in the world of fast foods, for example.

Maybe if insurance companies were permitted to charge people what we deserve to be charged based on our lifestyle habits, we'd begin to see these changes occur.  If I smoke, I pay more.  If I'm overweight, I pay a surcharge.  Make me feel my wallet lightening up if I don't take personal responsibility (just don't think this is your new way to raise taxes). 

Don't just continue to blame big health, or big drugs or big insurance!  You are doing nothing but pandering when you resort to this, and we're on to you!

Holiday Tree...

Marlin 'Snarlin Marlin' Schneider (D-Wisconsin Rapids) has a bill that could go before the Assembly to rename the pointy green thing with decorations on it from Holiday tree to Christmas tree.  Isn't that something?  Our Capitol rotunda has had a Christmas tree each year since 1916.  It was a Christmas tree until 1985 when we permitted our lawmakers to go off the track.  At that point, it became known as the Holiday tree, even though everyone who saw it called it by its correct name...Christmas tree. 

Our governor says the tree's name is irrevelant.  Again, I find myself disagreeing with the governor.  We have simply lost our bearings in this morass we call 'political correctness' and it is time for us to reclaim our Christmas tree.

Washington County Board...

As of this morning, there are now eight County Supervisors who have announced that they will not stand for re-election.  Wouldn't this be a great time for the Board to reduce itself to a more workable and less expensive size by deciding to take the vote and create 22 new districts from the current 30?  Supervisors don't seem able to take a risk that their position could be one that is eliminated.  This would solve that dilemma.  And there can be little doubt that 22 would be able to serve the constituency as well as or better than 30.

Supervisor Brady, why not take a shot at this? 

Mike Gousha Returns...

Area television just got a real boost with the announcement that Mike Gousha is returning to our screens with a Sunday morning show as well as political analysis and commentary at other times.  He is simply the classiest and best TV person we've seen in ages, and it is good to be able to look forward to seeing him.

Health Care Costs Unequal Across State...

An analysis by Citizen Action, a coalition of labor unions and grass-roots groups, just announced that health care costs vary by as much as 26% from one part of Wisconsin to another.  Eau Claire, Milwaukee and Racine had the highest costs while Madison, Janesville and Beloit had the lowest.  This study used the rates for the state employees' health insurance program.

There are two major factors at work here, in my opinion.  First, the Madison/Janesville/Beloit area is filled with state employees to the point that it is the largest employer of record, and it has greater competition among more provider groups.  Second, the Eau Claire, Milwaukee and Racine areas have less competition amongst provider groups coupled with fewer state employees.

These two factors combine to produce lower or higher rates respectively.  Insurance rates are a direct function of health care costs assuming that the relative health of citizens doesn't differ markedly from one side of the state to another.

Frankly, this disparity of costs will likely increase with the continued vertical integration of health care providers.

The announcement concerning the sale of Medical Associates to ProHealth Care has been expected for months and finally was made.  ProHealth will buy Medical Associates for about $40 Million and the deal is expected to close around the beginning of 2008.

ProHealth owns Waukesha Memorial Hospital and Oconomowoc Memorial Hospital.  Medical Associates has clinical facilities in Menomonee Falls, Hartford, Sussex, Germantown, and Waukesha.  The bulk of Medical Associates' 175,000 patients are admitted to Waukesha Memorial Hospital and to Community Memorial Hospital in Menomonee Falls.

Community Memorial is part of the Froedtert & Community Health system.  That system has agreed to consolidate operations with the Columbia St. Mary's system.

Finally, Advanced Healthcare is being purchased by the Aurora system, and Aurora is building a new hospital in Grafton which is the 'backyard' of Columbia St. Mary's.

There are still other smaller systems fighting for survival, but those named will be the major players and are likely to have absorbed the remaining hospital systems and physician practice affiliations.

My earlier blogs have discussed what all this consolidation could mean to those of us in the Germantown area.

First, Community Memorial Hospital is at risk of losing the bulk of its patient load.  Aurora has promised the doctors at Advanced Healthcare that their admitting patterns will not be changed for at least two years.  (Read that to say, we'll shift patient admissions from Community Memorial Hospital to other Aurora hospitals in two years.)  I don't have any idea of the language of the deal between Medical Associates and ProHealth.  But, ProHealth is buying Medical Associates to gain doctors and to get added patients admitted to its hospitals.

Clinics usually are cost centers for hospital systems.  Hospitals tend to lose money on the clinics they buy and operate, but make that back plus with admissions to their hospitals.

There have been continuing rumors of discussions involving ProHealth and Froedtert & Community.  If those systems were to consolidate, there would emerge a new 750 lb. gorilla to take on the existing 800 lb. gorilla named Aurora.

Again, I have no knowledge of those discussions, if they are even continuing.  If I were running any one of those remaining systems, I'd certainly have determined that my only real chance of survival would be to consolidate with others to get the scale needed to be a true competitor to Aurora.

This bears watching.

So far as those of us in the Germantown area, we're in for a bit of a roller coaster ride over the next few years so far as healthcare is concerned.  Not only will admitting patterns be involved that will determine where we are hospitalized, but the price of healthcare will hang in the balance.  Will consolidation lead to true price competition....or will it ultimately end true price competition?  It could go either way.

Junk mail is driving me nuts. How about you? Is there a real solution that we can use or are we doomed to continue to wear out our delete keys? I’ll be happy to pass along your recommendations.

Perpetual campaigning is robbing us Americans of our rightful expectations of government. This is vividly clear when we look at the federal government. It seems to be getting more rampant on the state level, as well. Every move at the national level is one of posturing, rather than governing, for the majority of our elected officials. And, too many moves on the part of our elected state representatives smack of the same.

General Petraeus, the commander of our forces in Iraq, delivers his assessment on conditions there in a week and one-half. However, both sides appear to not have the courtesy to let us decide what to think of his report. Instead, they have been positioning for weeks to tell us what he’ll say and what it’ll mean. No matter your persuasion, you can make up your own mind; I doubt that many of us need such assistance.

The Presidential candidates for both parties will likely be chosen by very early in 2008, and maybe even before the coming New Year’s Day. On the heels of the “perpetual” campaigning mentioned above, we have this rush to decision being thrust upon us by a handful of states. Would we be further ahead to have a single national primary to be followed in 120 days by the national election, as I’ve begun to hear discussed?

Governor Doyle’s hand has appeared as expected in the budget debate. Unfortunately, he is resorting to fear-mongering by citing this and that calamity about to befall all us Badgers because there is no compromise as yet, on a terrible budget I would add. According to him, our schools won’t be able to run, our state Medicaid system will fail the folks who depend upon it and the Republican’s failure to acquiesce will cause your property taxes to rise precipitously. His budget, even without the addition of Healthy Wisconsin which he does not support, has us paying 23% more than before. With Healthy Wisconsin, it only doubles! What a choice we have. The opposition must not cave in, but instead must continue to work to advance its more rational version of our next biennium.

Our Warhawks football team ran into the seventh-ranked team in the state last evening and came away with a much better understanding of its own weaknesses. Coach will build on this experience and our players will improve having gotten such a solid lesson so early.

Our new motorcycle patrol is having the desired effect. I have been amazed at how invisible that cycle and officer can be, and also marvel at my good fortune to have been at or under the speed limit each time…so far. If you’ve not given thought to the effectiveness of this unit, do so before you pay good money for a transgression.