Gas, meet fire.

I’m no economist. But I get math.

And so does the stock market. There’s a very good reason portfolio values have crashed; Congress just dumped a whole lot of gas on what was a controllable fire.

After eight years of slow but steady economic recovery we’re about to see a return to inflation – and all the bad stuff that comes with it.

Congress just voted to pass a budget that will add over $2 trillion to the deficit, weeks after ramming thru a devil’s brew of huge tax cuts for the wealthy, real estate investors, and big corporations.

The economic stimulus that will come from the budget and tax breaks is coming exactly when it isn’t needed – when the economy is well and truly recovered from the 2008 recession. Instead, this huge flood of cash arrives just as labor markets are tightening, wages are increasing, debt is getting more expensive and loans tougher to find.

In other words, inflation.

  • Government borrowing is about to increase a lot.
  • The cost of debt for companies, cities, states, school districts is about to go up – a lot.
  • Millions of baby boomers are retiring every year, hoping to live off their 401ks. Which are worth a lot less today than they were – and will likely lose more value in the coming weeks and months.
  • Demographics will drive health care costs ever higher – soaking up more of your personal funds and tax dollars.

From The Economist:

Public borrowing is set to double to $1 trillion, or 5% of GDP, in the next fiscal year. What is more, the team that is steering this experiment, both in the White House and the Federal Reserve, is the most inexperienced in recent memory.

American fiscal policy is being run by people who have bought into the mantra that deficits don’t matter. [emphasis added]

From Andy Roth, vice president of the conservative Club for Growth.

“With this deal, we will experience trillion-dollar deficits permanently…That sort of behavior, the last time I checked, is not in the Republican platform.”

From Paul Winfree of Heritage Foundation and former Trump economic adviser:

There will be ups and downs in the stock market, but the irresponsible combination of unnecessary tax cuts and huge increases in spending means inflation is inevitable.

And the current crop of morons in DC doesn’t give a rat’s ass.

What does this mean for you?

Electing responsible adults would be a good start.



An anesthesiologist on opioid addiction and treatment

Some doctors are changing the way they talk about and address pain, offering hope that fewer opioid addicts will be created.

And we are starting to learn how to better help those with substance use disorder – a term that better describes those addicted or dependent.

I learned a lot in a recent interview with Faye Jamali MD, a California anesthesiologist who found her brain “hijacked” by opioids.

According to Dr Jamali, It began with a fluke of an accident at a child’s birthday party, in which she broke her wrist. Two surgeries followed. Sidelined and in pain, Dr Jamali turned to painkillers prescribed by her doctor. Feeling increasingly depressed, and with easy access to drugs, Dr. Jamali began to inject herself, rather than heading to the ER. “That’s when my brain got hijacked,” she says, adding that “I knew nothing about addiction.”

After going thru the recovery process, she’s been sober for eight years, and recently left Kaiser Permanente to help other physicians recover. Here’s an excerpt from our conversation. (Note emphases are mine, and I while tried to capture her comments precisely I may have made errors)

MCM – How has pain management changed?

Dr Jamali – Over the last 4-5 years there’s been a big push to limit amount of narcotics prescribed. Before, it was taught that if patient has pain, just give them as much as they want…that’s changed, that isn’t being taught now, we are on the right track now.

[Instead medical students are being taught] multimodal analgesia, NSAIDs, nerve blocks, and to use PT more.

In California there has been a big push to look at pain holistically and change patients’ expectations about discomfort levels. You can help manage it using different medications and medical services.

MCM – Can you talk about specific changes you are seeing with pain management?

Dr Jamali – with pre-emptive analgesia, there’s less post operative pain if you block it first with nerve blocks [before surgery is performed], then keep using nerve blocks to reduce the need for opioids after surgery. We found that that the care type was key to minimize the amount of opioids needed pre- and post- surgery. Patients who have pain in the hospital are much less likely to get up and walk around, so [nerve blocks help patients be] ready for more activity.

Patient acceptance of pain is also important; We have worked to help patients understand about managing pain, by decreasing opioids or [prescribing] no opioids, you feel better because your mind will be clearer and you will recover faster. There are other ways to manage the pain, to get you comfortable enough to do your errands. Lots of positive reactions from patients to this as opposed to the last time they had this.

Patients have been very happy with the nerve blocks and nerve catheters… patients doing a second knee replacement said this [change in pain management] was night and day with them, [they were] more clear headed, more comfortable, could do their PT…We take pain seriously – pain impedes recovery, this different strategy was better for them.

MCM – For those already addicted– what has worked?

Dr Jamali – [The most successful] Programs for recovering physicians are completely holistic, not a 28 day approach, may be 90 days. Physicians in recovery should have a 5 year plan of what you should be doing; weekly group, Medication Assisted Therapy, practice monitors. For the general population it is extremely expensive to go to inpatient treatment.

12 step is the only one that is free, but there is very little data [on success rates] as it is anonymous.,. Basic data indicates [long-term success is] 8-10% [of patients], AA-type programs say it is higher. Patients do it because it is free. In and of itself it isn’t enough. Should be longer, include component of what made this person get into addiction, lot of times there are factors that enabled addiction, in many instances that isn’t covered [by these programs].

Relapse occurs because we aren’t treating the disease…we don’t only treat the first 90 days of diabetes…. It [substance abuse disorder (SAD)] is a medical disease that needs long-term treatment.

We need to think of addiction as a disease and not stigmatize it. As long as there is a stigma we won’t treat it as we do with other diseases. All evidence indicates it is indeed a disease, this is a powerful highjacking of the brain that leads to this behavior.

There should be national or state standards for treating SAD, requiring enough long term treatment…Can’t just lock them up, need to have a plan. There should be a gold standard for what should be offered to patients who are addicted right now. Look at the causes, what is needed to deal with that over the long term.

Public perception is changing, it used to be addicts are bad people, now we see doctors, soccer moms, teenagers who are part of the problem, they can’t get more drugs so are doing heroin.

MCM – What is the role of opioid manufacturers?

We dealing with the intersection of profits and what is best for society. Far too many pills are going to small towns. Incentives are in the wrong place. Free market has a role in many areas, in healthcare it should not be a free market system…Should not be a profit in treating patients with illness. There’s no financial incentive to prevent a disease if they can profit from it.

Key takeaways:

  • Substance Abuse Disorder is a chronic disease
  • We need to stop stigmatizing sufferers
  • Long-term multi-modal treatment is critically important




So much for the “Opioid Crisis”

A 24-year old is acting as chief of staff of the Office of National Drug Control Policy.

Of course he has no experience, qualifications, or background that qualifies him for this role. And, ts ONDCP has no Director or Chief of Staff, this kid has been one of, if not the, senior executives at the federal agency tasked with addressing the opioid crisis.

Taylor Weyeneth, who happens to be from our town, also submitted a resume to the federal government that exaggerated his “credentials” (he claimed a graduate degree he does not have).

According to newspaper reports, he was involved with a “family company” here that federal records show was “secretly processing illegal steroids from China as part of a conspiracy involving people from Virginia, California and elsewhere.” Weyeneth’s resume claims he was head of production for this company when he was 16.

Weyeneth is the symptom, the Administration’s complete lack of attention to the opioid crisis is the problem.

This personnel debacle follows the Administration’s attempt to appoint Tom Marino as Director of ONDCP. Marino is a politician that sponsored a bill greatly limiting federal oversight of the opioid industry. an attempt that fortunately collapsed amidst bi-partisan outrage.

Seven Administration appointees have left the Office over the last year; that’s more than 10 percent turnover in the 65 person office. There is no Director in place, and no indication there are any plans to appoint one.

The President gives speeches about the crisis, and claims the Administration is doing everything possible to attack the drug crisis – and Taylor Weyeneth is appointed Deputy Chief of Staff.

Words are one thing, actions another.

What does this mean for you?

We aren’t going to get any help from the White House on opioids.


We haven’t seen anything yet.

Healthcare is changing really quickly and quite dramatically. Stuff we never would have thought of is happening every day.

  • A huge PBM is buying one of the largest health insurers in the world.
  • Provider consolidation is rapidly accelerating.
  • Many insurers are vertically integrating; they own thousands of providers, care-delivery locations, and are racing to build even more infrastructure.
  • Private insurers are pushing hard and fast into the Medicaid and Medicare markets.
  • Pharma is making gazillions in profits and driving medical costs higher: many employers are beginning to rebel.
  • The world is finally taking opioids seriously, while many fraudulent and sleazy people and companies are looking to profit from the crisis.
  • Medicare and Medicaid are facing major changes; the Trump Tax Bill is just the beginning of efforts to cut benefits and reimbursement.

The healthcare infrastructure of 2021 will look a lot different than it does today.

A couple things to think about.

  1.  While scale is critically important, the bigger the organization, the harder it is to anticipate and adapt to change. Huge health insurers and healthcare delivery systems must force their people to take risks and innovate – but most of these institutions are led by executives with little tolerance for failure. 
  2. The fee-for-service system is deeply entrenched in our entire industry. Provider practice patterns, sales rep incentive programs, provider marketing strategies, employer healthplan purchasing priorities, hospital financial systems, billing and reimbursement infrastructure, insurer business models all are fundamentally based on fee-for-service. Improving outcomes and reducing costs cannot happen without disrupting the very roots of our healthcare “system”.
  3. Our healthcare system is vastly inefficient – and that is precisely why tens of millions of Americans live off that system. Disrupting that system will cost hundreds of thousands of jobs.

What does this mean for you?

The winners will be those that understand where things are going.

There are two basic strategic options: those with a long-term view must become part of the disruption or short-termers will have to carve out a niche that’s sustainable over the near term.

This is the third option, which most will inadvertently pursue.  Business-as-usual folks will wake up one morning and find out they’re toast.

GOP budget’s impact on healthcare

The budget resolution that Republicans are basing their budget on would cut $1.8 trillion from healthcare, mostly from Medicaid over the next decade.

The impact of this on healthcare would be akin to Harvey hitting Houston. 

We will leave aside Republicans’ wildly optimistic economic growth projections and Congress’ elimination of scoring by the CBO – but you shouldn’t. (from former Reagan and Bush economic adviser Bruce Bartlett, discussing GOP growth projections... “[it’s] wishful thinking.  So is most Republican rhetoric around tax cutting.  In reality, there’s no evidence that a tax cut now would spur growth.”

Instead, the plan would cut Medicaid funding by 30 percent over the next ten years and slash Medicare by another half-trillion dollars.

This is a massive cut, one substantially larger than those proposed in either of the GOP’s failed ACA repeal bills.

There are NO details on how these cuts would be made or which providers and beneficiaries would lose what. This is classic Washington; they don’t want to highlight any specifics because the lobbyists will flood their offices.

Without those details, it is clear that doctors, hospitals, clinics and therapists would all face massive cuts in Medicaid reimbursement, and millions of families and kids would lose coverage. 

If something like this becomes law;

  • doctors and hospitals are going to jack up prices and increase utilization for privately-insured patients,
  • insurance markets will be thrown into disarray as the budget blueprint slashes ACA subsidies, and
  • the health status of millions of kids will decline.

What does this mean for you?

IF something like this passes – which I believe is highly doubtful – the US healthcare “system” will be hugely disrupted, with major implications for employment, private insurance costs, and workers’ comp.

Coventry work comp services will NOT be sold anytime soon

It’s been apparent for some time that the senior suite at parent Aetna has way too much on it’s plate to even begin to think about selling off Coventry’s work comp unit.

That plate just got heaped with a whole lot more; CVS Caremark is looking to buy Aetna for $66 billion. (thanks to Richard Krasner for the head’s up!)

Reportedly the two companies’ CEOs have been discussing the potential deal for several months, which implies they are in favor of the transaction.

There’s a lot more to this – but I gotta hit the campaign trail.

For now, Coventry work comp isn’t going anywhere.

Improving healthcare will hurt the economy

Healthcare employs 15.5 million full time workers – more than 1 out of every 9 jobs. That’s more workers than the manufacturing industry. By 2019, healthcare employment will surpass retail.

Over the next decade, 9 of the 12 fastest-growing occupations will be in healthcare – fully a quarter of total job growth.

While that’s good news for folks working in the healthcare industry, those jobs are funded by employers and taxpayers  – and those funds are not available to buy other goods or services. Some argue healthcare is “crowding out” economic expansion in other sectors thereby hurting overall economic growth.  Moreover, much of healthcare is inherently inefficient; extra cost does NOT equal extra benefit. The US’ healthcare efficiency rating by the Commonwealth Fund was a miserable 11th out of 11 countries.

That isn’t exactly “exceptional”.

This from “The Health Care Jobs Fallacy” authors Katherine Baicker, Ph.D., and Amitabh Chandra, Ph.D.:

Salaries for health care jobs are not manufactured out of thin air — they are produced by someone paying higher taxes, a patient paying more for health care, or an employee taking home lower wages because higher health insurance premiums are deducted from his or her paycheck. Additional health care jobs leave Americans with less money to devote to groceries, college tuition, and mortgage payments, and the U.S. government with less money to perform all other governmental functions — including paying teachers, scientists, and social workers.

By the same token, “controlling” health care costs will cut employment, and pharma stock prices, and margins for medical device firms, and bonuses at healthplans.

This is where things get interesting.

If efforts to control healthcare costs and increase efficiency actually bear fruit, those lost jobs, reduced profits and lower margins will hurt the economy. At some point, the entities that pay those costs are going to may put the dollars to work elsewhere, but that’s going to take some time.  And, the money saved may just be parked in cash accounts where it won’t do anyone much good.

So, if the healthcare sector of our economy gets more efficient, the US economy will suffer.

What does this mean for you?

Healthcare is a huge employment generator, and a very inefficient industry.  Fixing that inefficiency will reduce employment and economic growth.

One wonders how this will affect politics and politicians.

What its like fighting the opioid industry

I’m struggling to find an analogy that fits how one-sided this fight is.

it’s not a knife-to-a-gunfight thing; at least you could throw a knife and have a chance of injuring your adversary – then run away.

it’s not a David v Goliath thing, because big pharma is VERY aware of “David’s” capabilities and vulnerabilities.

The best I could come up with is an ant vs. a boot.


A couple recent articles highlight how bad our collective butt is getting kicked (thanks to Steve Feinberg, MD – a colleague and pain management doc in CA).

While publicly vowing to help roll back opioid usage, the opioid industry is spending millions to convince state legislators to slow-walk efforts to reduce opioid prescribing, weaken PDMP usage requirements.  One telling datapoint; Pharma spent $880 million on lobbying and contributions from 2006 – 2015, anti-opioid groups spent $4 million on contributions to state political campaigns AND lobbying from 2006 – 2015.

In New Mexico, efforts to curb opioid prescribing have been defeated, thanks to an overwhelming push by big pharma.  The opioid pushers hired 15 lobbyists, contributed to most members of the key Committee working on the bill, and got what they paid for.

And it’s not just overt lobbying by pharma; these bastards are funding “patient advocacy” groups like the Cancer Network, creating their own “astro-turf” patient groups, even stuffing wikipedia with opioid advocacy crap and changing entries to delete negative information about opioids.

What does this mean for you?



Opioids – you have no idea.

Two people very close to me are on the front lines of the opioid disaster.  Working in ERs and ambulances in the northeast, they see – multiple times every day – how bad it is.

You have no idea.

The toll this is taking is wide, deep, and devastating.  Some public safety workers are burning out, beyond frustration and anger to a place of fatalism.

Yesterday an unconscious woman was admitted after her kids told their dad she was taking a nap on the kitchen floor.  The nap was induced by a very heavy dose of benzos on top of heroin; when dad came home from work – he’s a public safety worker too – she was unresponsive.

Revived with a hefty dose of Narcan, the woman “justified” her dosage as needed due to some unspecified mental trauma.

This one example is playing out multiple times every day for every ambulance crew, in every ER, in every neighborhood.  NPR’s morning news greeted me with a piece about elephant-tranquilizer Carfentanil, a made-in-China chemical that is exponentially more powerful than fentanyl, which is exponentially more powerful than heroin.  Now spreading rapidly thru Ohio, Florida, and the midwest, carfentanil will soon find its way into your town.

If you think I’m being alarmist, you’re wrong.

Here’s how this is impacting us today.

  • parents are dying in front of their kids.  who’s going to take care of those kids, and prevent them from following in their parents’ tragic footsteps?
  • To some public safety workers, Narcan is NOT saving lives, it is a Get-Out-Of Jail-Free card, allowing users to “safely” push the limits of dosing in their quest to get ever higher ever longer.
  • opioids may soon be replaced by drugs such as carfentanil.  Why grow poppies when you can just order this pill from a chemical factory in China?
  • Public safety workers are at the end of their ropes.  How can they not be white-hot with anger at users when confronted several times a day with parents “justifying” their using after being revived with Narcan.

This started with legitimate “prescription” drugs pushed by pharma companies making billions.  Make no mistake, these bastards are the ones who started the ball rolling, a ball that has gotten ever-larger and is crushing more and more of us as it picks up momentum.

The great late David DePaolo penned a piece on Purdue just days before he died.  It’s well worth reading, and remembering.

But the disaster unleashed by Purdue and their ilk is way beyond what any of us thought it would become.  As powerful and necessary as the Surgeon General’s letter to physicians is, it is so, so late.

Will this epidemic be solved by public health measures far greater than anything we’ve thought of or funded to date, or, like smallpox among Native Americans or the Plague in Europe, is it fated to burn out only after it kills most users, leaving no one else to infect?

Have a great weekend.

More insured via Exchanges is good news for Work Comp

People who obtained private health insurance coverage thru the Exchanges in 2014 were less healthy than those previously insured. A just-published article in HealthAffairs provides details on their medical issues and conditions, more on this below. [sub req]

That’s not surprising; prior to ACA, many individuals and families weren’t able to obtain coverage at a reasonable price, and some couldn’t get any coverage at any price, due to insurers underwriting practices.

Now that medical underwriting and pre-existing exclusions are outlawed, folks with health problems can get insurance.  Before we jump into the implications discussion, here’s the specifics.

among those with individual private coverage, the likelihood of reporting fair or poor health and the likelihood of being obese increased by 1.5 and 4.2 percentage points, respectively (Exhibit 1). We also found that the likelihood of having at least one of ten specific chronic conditions5 increased by 6.7 percentage points for this group—a change that was driven by increases in the likelihood of having hypertension (a 4.0-percentage-point increase) and diabetes (a 2.9-percentage-point increase)

The good news is many of these chronic conditions respond well to relatively inexpensive treatment, and the cost of caring for these individuals is much lower if they have access to good primary care.

For work comp payers, the good news is a bit less obvious – but it is good news – for two reasons.

First, in general the working population will be slightly healthier – because more workers will have insurance, and the least-healthy are more likely to be improving their health status. Thus if they do get injured, they will likely heal faster as their overall health status is better.

Second, work comp insurers won’t have to pay to treat their non-occ medical conditions, as the patients are more likely to have health insurance.