Reindeer Games

Christmas is on final approach, so I am going to invite you to channel your inner child, the one from so many years ago who was really banking on this Santa guy to come through. Oh, come on…pretend for just a minute.

In Monday’s post about the court decision to invalidate the Affordable Care Act, we noted the President’s tweet to the 2019 Congressional leaders: ‘Mitch and Nancy, get it done!’

That got us digging back through the What Matters archives.  Sure enough, there on August 19, 2016 we wrote about this magical possibility of President Clinton and Speaker Ryan setting aside their political differences and hammering out a more viable health care policy.

Oops, I totally missed the election of President Trump, which is why I stay out of the prediction business.

But at the time, the thinking among some Washington insiders was that she would need to save Obamacare from itself and shore up some of the fundamental flaws; he would like changes that would mitigate coming fiscal and deficit risk; that might be just enough to lead to cooperation.

Now we fast forward to reality and a time when the idea of cooperation seems even further fetched that a rather large chimney sweep with a penchant for red velvet and flying sleighs.  But in the spirit of the holidays, allow me to ponder a similarly wild scenario for elves Trump, Pelosi and McConnell.

First, we know the Big Elf is fundamentally a deal maker, more than a policy purist.  And getting a deal done with people he has previously insulted (see Canada, maybe China) seems to bring a special joy.  Did you see the Trump, Pelosi, Schumer spat the other day?  Just saying.

Trump and the Republicans know that if the ACA is officially killed on appeal by the Supreme Court, they then own the whole issue, including finding a way to make the ban on preexisting conditions work economically for everyone.  That will be a trick.  Cutting a deal with Nancy to share that ownership might not be all bad.

McConnell has to be thinking about having this conversation in 2021 with Pelosi and President Biden/Sanders/TBD.  Having another Republican, even an unpredictable one, at the table now might not be all bad.

The real wildcard would seem to be Pelosi.  Do the Democrats have enough to gain to work on it now with Trump?  Can they really work on something this big with someone they are trying to impeach? Do they just wait for the inevitable control of the White House, just as it was in 2016…oh wait…that didn’t quite work out, did it?  Negotiating with Trump, who might really need a deal if that China thing doesn’t work out, might not be all bad.

Yes, I am hearing hoof beats on the roof.

Outrunning Inertia

We are in a series outlining the big ideas that would serve as the foundation for Tim’s proposed healthcare reform plan.  Click here to find the prior posts.

So, we gave some thought to taking all the posts in this series on my reform plan and compiling them into a book.  When explained the idea to the publisher, they informed us we’d have to classify and market it as ‘children’s fiction.’  Apparently, the idea of common sense healthcare reform is a pretty wild, fanciful notion.

OK, OK, everyone likes to classify their own stuff as ‘common sense,’ so we won’t walk too far down that road lest we pull a muscle reaching around to pat our own back.  But, we can say with a high degree of confidence that common sense or not, the ideas we’ve outlined have about the same probability of being passed as I have of finding two surprise tickets to ‘Hamilton’ in my sock drawer. 

Yes, ‘Hamilton’ is coming to Denver.  Yes, our oldest (the cultured one among us…must be from Mom’s side) has made clear that it would be hard to imagine a better night for she and I to share than my taken her to Hamilton.  I agree and I am constantly checking the online ticket exchanges, though that somehow feels like I am putting a price on how much I love her when I do that.  Thus, the hope of finding tickets mysteriously hiding in the laundry.

The big take-away from this whole exercise, at least for your practice, is this:  Inertia is a powerful. 

Washington is not likely to make any game changing moves anytime soon; the status quo will continue to deteriorate, especially since the administration believes that collapse will help its strategy.  In spite of the game being rigged in favor of the big monoliths, progress will be slow to non-existent and the crisis will just continue to worsen.

In the meantime, the ‘market,’ and by that I mean real people – individuals and companies – paying real bills will continue to seek better solutions NOW.  It is funny how having to live on a budget tends to change your thinking.  And because of that, rapid innovation, both from those on the edges of healthcare and those on the outside just coming to the party, will continue to happen at a torrid pace.  This will, of course, be far and away the most interesting ‘reform’ we experience.

Which is why, still, we are bullish on the prospects for independent physicians in the coming years. 

So here’s our simple advice…as we’ve done here at What Matters for the past three months, ignore the Washington noise.  Just focus on your business in your markets with your patients and get after it. 

You just have to out-think, out-execute, and out run the inertia.  And you know, inertia is not gaining any momentum.

[Got to love the bad physics jokes, which I understand is redundant.]

In the meantime, if you happen to be close personal friends with Lin-Manuel Miranda, give me a call.

One Path to Bliss

We are in a series outlining the big ideas that would serve as the foundation for Tim’s proposed healthcare reform plan.  Click here to find the prior posts.

In 1742, Thomas Gray wrote Ode on a Distant Prospect of Eton College.  Most of you prefer his other, more famous poem, Elegy Written in a Country Churchyard, because of its literary —


If you have had been paying attention to your IT folks about being on guard for suspicious emails, you should have deleted this immediately.  ‘This is referencing 18th century English poetry. It can’t be from Tim Coan.  This has to be a scam.’

But if you are still with me, in Ode we find one of Gray’s most famous lines:

 ‘Where ignorance is bliss, ’tis folly to be wise.’

While Mr. Gray was reflecting on his youth and not advocating a strategy of sticking your head in the sand to ignore hard realities, many have seemed to adopt his line as a life motto.  After my deep dive this summer into the healthcare mess, maybe it is good advice. 

The truth here is not pretty.

About a year ago, we were putting the finishing touches on our white paper, ‘Eventually, Gravity Wins: The Case for Independent Physicians.’  I won’t repeat all of the numbers here, but the math was staggering.  The economics of healthcare are not working at any level – consuming too much government spending, devastating family finances, burdening corporate expenses, reducing provider reimbursement – and are getting worse.

After coming at this from a slightly different angle this summer, I am convinced I misstated the problem: it is worse than I conveyed.

I won’t get too lost in the weeds here, but as I have telescoped out and looked at this from an even broader perspective, I am now more convinced than ever that we are heading for a major economic catastrophe as a country and our inability to address the healthcare mess is, and will be, one of the top contributing factors. 

No, I am not predicting the Dow will lose 3,000 points next Thursday, but a growing number of really smart people who have charts and graphs say the simple math of demographics (translation: lot of old Boomers consuming entitlements and not contributing to production) and public debt (translation: What do you mean the public pension, Social Security, Medicare, Medicaid credit card declined?) gets really ugly, somewhere in the 2025-2030 range.  (If you are interested in learning more, drop me an email and I’ll point you to a couple of resources that have informed my thinking.)

We can’t really do much about all that post-World War II celebrating that caused maternity wards to bulge nine months later, can we?  (Like that pun?) And if we don’t have the moxie to really work on healthcare maybe blissful ignorance is a better way to enjoy the next few years. 

In the short run, this all presents opportunities for independent physicians, IF we will take them. 

We’ll wrap up this interminably long series on Friday with that good news.

Isaac’s Falling Apples 

We are in a series outlining the big ideas that would serve as the foundation for Tim’s proposed healthcare reform plan.  Click here to find the prior posts.

After amusing myself for over three months now, and hopefully sharing a provocative thought or two along the way, I am left to ponder whether any big ideas will ever be implemented.  I am generally an optimistic guy, but with a note of despair and resignation befitting of Hamlet or a Giants fan, I have to conclude it is not likely.  With either party.

The Democrats had control and at least passed SOMETHING, though that is sort of like the equivalent of spraying water on a grease fire.  Yep, you did something…accelerated the burning down of the whole house.  History will decide if they get credit or blame, though there will be two versions of the story, so you can pick whichever you like.

That is better than the Republicans, so far, though I feel safe betting the rest of their time in control looks a lot like what we’ve seen so far.  Momentum is fickle in Washington, especially when that comes with a slim majority in the Senate, raucous factions in the House, and a President that may or may not be a Republican.  The repeal and replace pledge may not get fulfilled, but the promise to be unpredictable has been kept, hasn’t it?

So what happens?

‘Eventually, gravity wins.’  Thanks Newton.

It sometimes wins fast, as when a four-year-old jumps off the top bunk and realizes that not every bed sheet has flying superpowers.  Sometimes it is slow, taking years of rust and decay before the steel girders give way and the building topples under its own weight.  But given enough time, gravity’s track record is pretty good.

This thing is going to break, sooner rather than later. Evidence of present crumbling is all around. To mix my metaphors, Democratic actions added a lot of weight to a well-rusted building that was already too tall for its own good. 

But the dysfunction of our current political system is such that we’re most likely going to do little more that apply some duct tape and then move on to blaming the other guy for it not working. 

I was talking to an old friend the other day, a guy who just retired from a long and successful career as a very innovative healthcare executive.  He now as the advantages of both a lot of history and the luxury  to look far down the road.  Knowing this post was coming, I asked his prediction on where this will go.

It has to completely fail, was his take, before we can muster the courage for moderates on both sides of the aisle to come together and forge a sustainable compromise.

Unfortunately, I think he is right.  More unfortunately, a lot of people will get really hurt in the process.

OK, you might want to skip Wednesday if this is getting you down because I have one more of those doomsday posts before we close this whole thing on Friday (finally!) on an upbeat note.

Then There Was One

We are in a series outlining the big ideas that would serve as the foundation for Tim’s proposed healthcare reform plan.  Click here to find the prior posts.

One of the ironies of this blog thing is what is missing.  Often, our discussions here are rooted in numbers, what with my being a pretend economist or policy wonk or whatever analytical superhero I imagine myself to be that particular day.  Yet I almost never use graphs.

The folks I work with every day would testify how unusual that is.  They can’t give me a spreadsheet about anything without me immediately grabbing a bunch of cells and throwing down a graph, complete with the 2nd order polynomial trend line (that is real, and yes, I use it all the time…it makes me look smart).  Heck, my wife and kids make have been forced to endure a graph showing how often we drive through Chick-Fil-A.

I rarely use graphs here, for two reasons.  The first is self-protection.  I totally dork-out when I start down the road of playing with data and graphs, but I have to hit the posting deadline. It is a time-management discipline.

Second, most of the time, I turn a graph I find somewhere into a 500 word post, which is handy for me.  If I gave you the graph, you’d glance at it, get the point, and stop reading my blog. 

But today, I come to my final ‘this is going to be really hard to solve’ problem and realize I only have 250 words left.  So, I’m going to break my rule take advantage of the 1,000 words found in a picture and cheat. 

This is my single favorite healthcare chart, period. Steal it, use it.  It comes from the 2009 work of Professor Fischbeck of Carnegie Mellon University and the most important things you need to know about US healthcare are in this graph.

The fact that we spend, per capita, 2x the rest of the developed world on healthcare is bankrupting us.  So we passed the biggest piece of domestic legislation in a generation and blew up one-sixth of the economy, but it never dealt with this fundamental reality.  And the Republican plans aren’t addressing it, either, so this is bi-partisan stupidity. 

Let’s be really blunt: We don’t have a healthcare spending problem…we have a problem with what we spend on seniors.  And that is a toxic issue that no one wants to touch for a million reasons. But until we solve this, everything else is just rearranging deck chairs on the Titanic.

It is inevitable that older people require more care.  It is biology, physics and chemistry all rolled together.  But as the chart shows, we are doing things way, way different from the rest of the planet.  And we’re toast.

Politically, morally, and probably a couple other ___allys, this is dang hard.  But economic reality is going to solve it for us if we don’t.  Soon.  Collapse is blunt instrument that brings a lot of pain.

Next week, we’ll share some final personal reflections from this 100 day journey through Timmy’s World and then call it a wrap.

The Black Dog

We are in a series outlining the big ideas that would serve as the foundation for Tim’s proposed healthcare reform plan.  Click here to find the prior posts.

Being a bit, shall we say, ‘unfiltered’ here is a good thing most days.  I get to be a smart aleck, ramble a bit, incorporate a random tangent or some weird redneck euphemism and that just ‘fits with the brand positioning.’ More simply, we get to think about big healthcare issues without taking ourselves too seriously.  I like the formula.

But every once in a while we come up against a topic that just doesn’t lend itself to sarcastic humor, at least not without running the risk of being unintentionally and unnecessarily offensive. While that sounds like advice someone might offer the Tweeter-in-Chief, we’ll also heed it a bit as we tackle another really hard issue – mental health.

There is no easy way to talk about mental health, which of course, is itself one of the challenges in dealing with this.  But if we are to make real progress, better solutions around mental health could have a major impact.

Here’s some context for why I think this matters…

One in five Americans experience mental illness in a given year, with the black dog of depression and its closely related anxiety disorders being the most common.  Yet 60% of those people get no treatment for a variety of reasons. 

Access is one of those reasons, as anyone who has experienced mental illness, directly or through a family member, will tell you.  Unless you walk into an ER and report the code words that things are so bad that you are thinking about hurting yourself, getting to a provider requires running a gauntlet that no one, especially someone suffering from mental illness, can muster.  Networks are small and benefit plan coverage is often limited.  Yet, psychiatrists are the lowest paid of all of our clinical specialties.  Yes, healthcare can magically suspend even the law of supply and demand.

Besides how we provide and pay for mental health services directly, co-morbidity is the other major issue.  7 out of 10 people with a mental illness also have a general medical condition.  Looking from the other angle, almost one-third of the people with a medical condition also have a mental health disease.  A lot of people are in the overlap of the Venn diagram.

This matters for a dozen reasons.  A person with major depression who can’t get out of bed and shower probably is not highly compliant in taking his blood pressure medication, either.  And if a healthy diet and regular exercise is key to keeping her diabetes under control, well, that ain’t happening, is it?  Add the high prevalence of lower socio-economic status and bad health behaviors like smoking and drug use to this population and you get a hot, expensive mess.

I don’t have a great answer here because this is like fat marbled throughout the steak, which is fine in a nice ribeye, but this is just a metaphor for a complex problem.  Because of the multiplicative effect of mental illness, any progress could have a major positive payoff.