June 2010

Crisis in the Gulf

By Michael J. Katin, MD

It has been noted that the news media are capable of concentrating on only one story at a time. One would think that the foreclosure crisis no longer exists, or that Iran has stopped working on developing nuclear weapons. This being the case, when reference is made to "the Gulf," it has to be determined which of several possibilities are to be brought to the forefront. Would it be dealing with the disastrous oil contamination of the Gulf of Mexico ? Could it be a worsening of the threat to commercial shipping in the Gulf of Aden by pirates? Has there been a change in the precarious balance of power in the Persian Gulf? Or is it the most serious of all: the broadening gulf between our government's stated objective to provide medical care to everyone, versus the reality of trying to pay for it?

Certainly the intentions have always been good. Everyone would agree that nobody should go without medical care just as no one should go without food. Well, maybe not exactly. In restaurants, there are not tables of people eating for free with their bills being divided among the other diners. Regardless, if we think we should be responsible for each other, we need to have a formal system in place to cover the expenses of those who are less fortunate.

It is not the intention to cover the history of provision of human services, except to call attention to the fact that nearly every attempt to help humanity in general becomes complicated when actual humans are involved. When Cain asked the Lord, "Am I my brother's keeper?" he had already offed him. In most "ancient" civilizations persons of lesser means were provided care thanks to their being in captivity. Later, religious organizations expedited the practice of the virtue of charity by setting up poorhouses, almshouses, and other such facilities. These were later run by national and local governments, diversifying into workhouses and poor farms. . Interestingly, the first legislation was the Ordnance of Labourers Law of 1349 in England, which had an ulterior motive of forcing everyone to work due to the labor shortages following the Black Death, seeking to reduce the population of beggars in exchange for providing food and shelter. The Elizabethan Poor Law of 1601 went much further, including establishing taxes to pay for these institutions. It would hardly seem to be a coincidence that a scant 409 years later the economy of Great Britain is on the verge of collapse.

What would be the best way to take care of everyone's needs and still be able to afford it? It must be recognized that most efforts are penalized by their own success. I seriously doubt he President of the United States would be as concerned about contamination of Louisiana marshland if the South had won the Civil War . We would probably not be spending money building schools in Iraq if Operation Iraqi Freedom had failed . Similarly, thanks to advances in medical science, not only are people living longer but there is more and more that can be done both proactively and intensively. In 1910 the life expectancy in the United States was 50 years and is estimated by the Census Bureau as being 78.3 years as of this year. Now that the bureaucracy has figured out that it has gotten itself into a quagmire about achieving its goals, legislators have turned on two of the most innocent, vulnerable targets to try to pay for everything else, specifically, physician reimbursement under the SGR, and utilization of radiation therapy. The American Medical Association made resolving the SGR problem the main priority for its 2009 program , supported the Administration's Health Care Bill, and the SGR reduction, now over 21%, is still imminent . I need not discuss the struggle to determine the parameters for use of technologies such as IMRT and IGRT. It seems probable that reimbursement will decrease, and restrictions on utilization will increase, and more detailed regulation of diagnostic and radiation therapy equipment and its operation will be implemented will be proposed. Fortunately, there is a solution.

The solution is for the field of radiation oncology to be treated equally to every other entity regulated by the Federal Government.. For too long we've been agonizing on what will happen when the next directive comes out from CMS and from the regional carriers , The secret is for us to let the government do whatever it wants, and then not to take it seriously. We simply request the same degree of oversight as was placed on the following:

  1. Banking and finance
  2. Fannie Mae and Freddie Mac
  3. Coal mining
  4. Off-shore drilling

This way everyone's happy. The government gives the impression it's in charge, and we get to do whatever we want. Let's see how that works.

If it doesn't, we can always blame it on George W. Bush.