Are Some Physicians Stockholm Syndrome Victims?

A hostage sides with her
captors in a bank hold-up

Years ago, when the Population Health Blog was the staff physician supervising an overworked inpatient consult service, its team of residents was asked by a surgeon to evaluate abnormal kidney function tests on one of her patients. After quickly surmising that the cause was a simple case of easily-corrected dehydration, the residents complained that the surgeon should have spotted the diagnosis. As a result, they said, this was a waste of their time.

"Not so!" said the PHB. It pointed out that the resident's medical knowledge was so advanced that they could glance at some lab numbers and spot the diagnosis. It's not that the surgeon was dumb or lazy, but that they were extremely smart.

The PHB also challenged them to snap out of it. Their low self-esteem was allowing them to be held hostage by narrative that not only devalued their expertise, but put their professional well-being at risk.

Fast forward to today when it's not about troubled kidney function, but a troubled healthcare system.

As we look for solutions, physicians are being buffeted by a widespread narrative that they're largely responsible for low quality, high costs and poor patient experience.

For example, there's literature that physicians order too many or (too few) tests, that misdiagnosis is common and that their treatments warrant scrutiny.  Or, thanks to their "power of the pen," misaligned physician incentives have led to the United States' outlier status on life expectancy vs. per capita costs.

How much is truly under the physicians' control is up to debate. What's more, physicians bring tremendous value to the table of health reform.  But, public perception says otherwise, and that's likely playing a role in the declining public trust in physicians and drops in their prestige. That, in turn, is contributing to widespread professional dissatisfaction and burn-out with significant implications for patient care.

Which makes the PHB wonder if it's witnessing the consult service scenario described above, but on a national scale.  It's one thing for its physician colleagues to emotionally struggle with the tectonic challenges of health reform (and there are ways, like this and this, to deal with it), but it's entirely another thing for them to agree that their professional value has been diminished.

Which leads the PHB's to speculate about its biggest fear. In addition to the hassles of physician-owned practice, the intellectual and emotional buy-in of a narrative of incompetence may be leading many docs to willingly outsource national policy as well as local practice decisions about quality and costs to the corporation.

For some docs, this could be a professional version of the Stockholm Syndrome.

As so elegantly described by Paul Levy in his blog, the Stockholm Syndrome occurs when hostages misinterpret the near-term lack of abuse by their captors to the point of emotionally bonding with them. While he was writing about the relationship of healthcare institutions to electronic record vendors, the PHB wonders if the same could be said about the relationship of physicians to their administrators, policy makers, elected representatives, regulators and the other clerisy.

Their reward for any role they've played in marginalizing physicians is greater authority, and some docs may not only going along with it, but embracing it.

The PHB looked for physician surveys or other data to support this, and can't find it. It suspects no one has asked the question.

Until now.

A Health Care Clerisy?

We're here and we've figured it out

The Population Health Blog is reading Joel Kotkin's "The New Class Conflict." While it hasn't gotten through all of it, the central premise is a refreshingly alternative explanation for our
national malaise. 

It's less a matter of conservative vs. liberal ideologies that are leveraging class warfare. Rather, it's us vs. an unholy alliance of the new internet-media Oligarchs and their fawning expert clerisy.

"The New Class Conflict" doesn't dive into the implications for health reform. That naturally prompted the PHB to apply Mr. Kokin's lens to our healthcare expert class. 

Let the readers decide if this shoe fits. It may be paranoid, but it sure is fun to think about.

A quick word on the Oligarchs: these are the fabulously wealthy who dominate Silicon Valley.  They truly believe their template for success can change society for the better. They are very willing to deploy their new-found billions to promote their progressive, technological and green mindset.  The fact that their solutions are enormously self-serving makes them no different than the industrial barons of the 1930s.
   
Enter their health reform "clerisy" allies. They are made up of a growing academic, media, not-for-profit and government-worker technocratic class.  Armed with their science-based insights, they are advocating, lobbying, funding and regulating away an old health care order previously dominated by church, lay-business and volunteer organizations. Markets and ownership are being replaced by the priestly wisdom of an unelected elite presiding over a regulated utility. And they are being cheered on by their liberal-progressive and highly creative allies who dominate the old and new social media.

Opposing views are not only unwelcome but drowned out by a self-reinforcing echo chamber of this clerisy's group-think. Unapproved thoughts on, for example, the old-fashioned ability of health insurers to pool risks, the virtues of fee for service to incent access and the merits of small physician-owned private practices are tut-tutted as sadly misinformed. The few who rise above the noise are labeled as in the pockets of fat cats or being right-wing ideologues. 
   
And who should be surprised that the oligarch's interest in information technology dominates their health care agenda? Electronic records will save health care from itself, decision support will usher in a new clinical wisdom and big data today will lead to miracles tomorrow.  And by the way, if that leads to additional billions flowing to the oligarchs, all the better.  All that remains is figuring out which city they should buy an estate in so that they can run for elected office and legislate a single payer system modeled after Microsoft and powered by Google.

Their hardest job?  Persuading consumers as well as front-line health care workers to "work against their material interests or traditional beliefs." Think about paying more for energy, giving up control of education  and letting the NSA troll Facebook's data for bad behavior. In the healthcare space, patients must agree to consume less health care with health insurance they don't want while letting more of their personal data be used. Front line providers have to do more with less income, less control and less prestige.
. 
Oh, and the clerisy and their oligarchs remain personally insulated against the very policies that they promote for everyone else. If they need health insurance, it won't be a Bronze plan from an Exchange any more than they'll give up their big cars, private schools and internet privacy.

It's the 1% alright, but they're hiding in plain sight.

Frightening thoughts.

Health Care Cost Insights and Capitation for the Patient Centered Medical Home (PCMH)

The Population Health Blog finally caught up with the Oct 22/29 "Price, Cost and Competition" issue of JAMA. 

One of the more interesting articles was a Viewpoint editorial on the Patient Centered Medical Home (PCMH). After tut-tuting fee-for-service payment as antithetical to meaningful payment reform, the author admits what the PHB has been saying all along: a global payment that covers all the medical, coordinating as well as non-physician services of the PCMH is tantamount to old fashioned "capitation." As we learned in the 1990s, capitation's unintended consequences are a) signing up too many patients, b) limiting access to primary care and c) over-referring to specialists.  To counter that, the editorial's author suggests the PCMH movement seeks "accountability." 

We'll see about that.

In the meantime, some other interesting articles:

Are "for-profit" hospitals evil?  Not necessarily.....

237 hospitals that converted from not-for-profit to for-profit anytime between 2003 and 2010 were compared to 631 hospitals that had not converted.  Converting hospitals improved their financial margins (practically all were in the red and subsequently became break-even) vs. the comparison group, and did so without increased utilization, restricting access to care, higher death rates or declines in quality for their Medicare patients. Their path to profitability may have been lined by renegotiated commercial insurance contracts, cutting costs or moving non-performing assets off the balance sheet.

Can physician groups become monopolistic? In a word, yes.

Commercial insurance preferred provider organization (PPO) charges for ten types of physician office visits in ten different specialties across 50 states were correlated with a measure of local market dominance dubbed the "Hirschman-Herfindahl Index" (more on that here).  As the HHI index increased, payments also increased, suggesting that as much as additional $3 to $12 in fees for the same services were the result of monopolistic contracting.

Monopolies aside, if docs are in charge vs. the hospitals, can they reduce health care costs?  Also yes.

This study compared average "per-patient expenditures" of physician-owned versus hospital-owned integrated medical groups and independent practice associations in California from 2009 to 2012. Among the 158 groups, 118 were owned by docs; their expenditures were over a thousand dollars less compared to hospital owned groups.  Larger physician groups had higher expenditures than the smaller ones.  More on that in a future post.

Does price transparency help patients chose to spend less?

Over 500,000 insurance plan enrollees had special on-line access to prices for medical services prior to using them.  There were over 250,000 households and of these, approximately 7500 accessed the information. Compared to households that didn't check the information, the price-shoppers seemed to choose cheaper labs (a few dollars per test) and imaging options (about a hundred dollars per test).  In looking at the data, the DMCB suspects some may have also deferred testing by choosing to use them less frequently or not at all.

The Looming Credibility Trap of Obamacare?

While the young Disease Management Care Blog was first introduced to the concept of the "credibility gap" by Lyndon Johnson's Vietnam war, it wasn't until it started paying attention to blogs that it ran across the term "credibility trap." The former describes a disbelieving citizenry, while the latter describes a disbelieving government.

Enter this telling PolitcoMagazine article on the travails of being a Washington DC Cabinet Secretary.

In the modern course of our Republic, there are 23 talented overachievers who nominally preside over a huge federal bureaucracy. The DMCB thinks of that as the core machinery that lies at the heart of the liberal promise that Big 21st Century Government Can Accomplish Great Things.

If the Politico article is correct, successive White House Administrations have marginalized the Secretaries, letting the majority of Washington DC run like some side-show perpetual motion machine. As the DMCB understands it, that leaves the White House to insource the management of the really important stuff, like getting reelected or reversing rising ocean levels.

And so it was when it came to the implementation of the Affordable Care Act. Looking past the partisan cacophony, it appears the White House genuinely counted on HHS to smoothly implement the health care marketplace and its various mandates. What happened was a fumble of historic proportions that will continue in the weeks and months to come.

While conservative pundits are using the Obamacare imbroglio as another tiresome I-told-you-so lesson in government overreach, the DMCB is worried that the bright men and women who are responsible for implementing health reform are getting a crash course in the cynicism of the credibility trap.

Statutory deadlines are now meaningless. Regulations can be ignored. Being "on message" trumps the truth. Czars go into private equity so that lobbyists can become insiders. Political expediency is allowed to batter markets. Blowback begets stopgap crisis management by an insular political elite.

And as 2014 is threatened by death spirals, corrupted commercial enrollment data, unpleasant out-of-pocket surprises for consumers, small as well as large business market rate shocks, unpredictable legal challenges and further mischief by an emboldened Republican opposition, it becomes less a function of whose "fault" it is and more of a dreary exercise in keeping the Amtrak of health care from running off the rails.

The folks running the government bureaucracy are stuck with this lemon. Many are probably thinking that they deserve better.

Is the DMCB reading too much into the symptoms of C.T?

You be the judge.

Let Them Eat Cake: Stepping Outside the Health Care Reform Comfort Zone

How would Ms. Antoinette
ponder health reform
with her advisors?

While commonly attributed to Marie Antoinette, the phrase may actually be testimony to Jean Jacque Rousseau's genius in using four words to capture an elites' inability to grasp the plight of a struggling underclass.  For a more modern depiction of a lifestyle bubble, think of the 1% not getting just how difficult it can be to make a living wage.

And it's not just the 1%. African Americans, with some justification, note that whites have yet to grasp "the set of experiences and a history" that perpetuates racial inequality. It's not just the "facts" but how facts are sorted, prioritized and interpreted by a brain wired by decades of being surrounded by like-minded people caught up in their information loops.

But it cuts both ways. When confronted by the hostility of tens of millions of Americans to the Affordable Care Act, liberal-progressives likewise respond with similar puzzlement. Who can blame them for rationalizing things with attempts to provide more "education" or blaming it all on obstinate Tea Bagger and "Birther" wackiness?

It's not that simple.  As pointed out in this The Atlantic article, conservative skepticism about the size, regulatory reach and spending of government was well underway long before Mr. Obama set foot in the White House.  Focus groups have little trouble finding deeply held opposition to expanding government entitlements, middle class dependency, pro-business globalization, wealth transfers and scary levels of deficit spending. Given the big picture,  Obamacare is less of a problem than a symptom. 

As result, even if the White House and its Democratic allies prevail on the shutdown showdown, successfully raise the October 17 debt ceiling, cancel the January 1 2014 sequester and take back the House in November 2014, the opposition to the health care law isn't going to simply fade away.

But, say my liberal friends.....

1. Much of the Affordable Care Act is based on Republican ideas, including the mandate and Romneycare.

The mandate and Romneycare were never intended to be imposed nationally, but adapted by each of the states. 

2.  It will save money.

Health care consumption declined before the passage of the Affordable Care Act. Experts legitimately disagree on the impact on future health care costs but it stands to reason that more people with insurance will lead to increased demand and higher spending..

3.  The health care system is broken

Actually, the part of the system that was broken was the individual insurance market.  This objective OECD Report summary points out that, compared to many other developed countries, U.S. quality has been quite good and our cost trends are lower.  And while it's too early to tell, the health insurance exchanges travails combined with multiple other self-inflicted wounds suggest that the cure may end up being worse than the disease.

The point here isn't who's wrong or who's right.  Rather, it's clear that skepticism over Obamacare's ability to deliver on all its promises is not crazy.  Its critics not only deserve their time in the public square but to have their preferences reflected in policy and legislation..

What's more, the Obamacare dust-up is part of a bigger concern over the expanding role of government that tens of millions of Americans find potentially intrusive and unaffordable.  The inability of the DMCB's liberal progressive colleagues to comprehend that may be a less a function of their superior intellect or the stupidity of the opposition than an Antoinette-esque inability to step outside their familiar biases and ponder a different point of view. 

Valuable Personal, Political and Health Reform Lessons, Courtesy of the Federal Government Shutdown

Coming to consensus
the old fashioned way

The Disease Management Care Blog views the federal government shutdown with the same morbid fascination of watching personal injury lawyers justify their double digit malpractice suit contingency fees: it's so awful, it's hard to look away.

The good news is that that doesn't mean that the shutdown doesn't hold some important personal and political lessons.  They can make DMCB readers better citizens and our political class a credit to our Republic. 

To wit......

When the DMCB spouse expresses consternation over the boneheaded actions of her husband, the DMCB can now respond by:

1. changing the subject,
2. retreating to the DMCB World Headquarters and blogging about the spouse's unreasonableness,
3. referring to the alleged lapse as a "glitch."

Things don't go well in the opening day of a widely anticipated unveiling of the largest health care achievement in the history of the United States.  If you were in charge, you would respond to the health insurance exchange breakdown by:

1. recognizing the problem and promising to fix it,
2. reminding the public about the painful gap between lofty campaign promises and disappointing bureaucratic reality,
3. shrewdly drawing flattering comparisons to Apple, the most widely admired brand in the world.

As the leader of a political coalition, you are stymied by the division of powers in the world's longest lasting democracy.  In response you:

1. seek consensus
2. deploy ad hominem attacks in press conferences
3. offer to compromise by allowing the opposition to do things your way.

Wanting to be an informed member of the electorate, you regularly watch either CNN, FOX News, MSNBC, PBS, CBS, NBC or ABC because:

1. These broadcasts' news editors subtly frame their closed information loops to meet your own political biases,
2. You haven't discovered BBC or Al Jazeera
3. There aren't any movies on TV featuring svelte vixen vampire babes having their way with their mesmerized male victims.

By pointing out that Obamacare is "the law of the land," you are really saying:

1. Our representative democracy passed legislation that was signed by the President and upheld by the Supreme Court, so get over it,
2. Now wait a minute, our representative democracy can modify or even roll back health care laws.
3. Enough with the debate, time to move on and figure out how to make preschool education, low interest mortgages and low-fat frozen yogurt protected federal entitlements.

Being a Game of Thrones fan, you wonder if the following might not be useful in settling the budget impasse:

1. Asking what the honorable Ned Stark would do, until you recall that he was beheaded.
2. Invite the opposition to a Red Wedding
3. Call up your elected representative and say "Hodor!"
4. Call up your elected representative and hear him or her say "Hodor!"

State Medical Societies: Obamacare's Early Warning System

A canary for the health care reform mine

The Disease Management Care Blog has a theory.

Whatever you think of health care reform, there is a possibility that its implementation could be troubled for years to come.  Too few healthy young people could sign up, provoking an upward insurance cost spiral.  Bureaucratic meddling could further increase administrative burdens. Washington DC's political and fiscal woes could erode fee schedules.  Large regional delivery systems, saddled by inefficient capital, workforce salary inflation and overly optimistic risk contracting could become stressed.  The medical-industrial complex's bubble won't necessarily burst, but increased demand and less money could mean a painful contraction.

What will be the first signal that that's happening?

It won't be the pronouncements from the intelligentsia running HHS. It won't be a late Friday press release from the White House. It won't be a breaking news report from the clueless reporters in any of the major media outlets.  And, unfortunately, it won't be in a prescient posting by the DMCB.

It'll be an uptick in physician membership in 50 state medical societies, followed by phone calls their affiliated professional liability insurance brokers.

The DMCB is talking about the state organizations that largely make up the base of the American Medical Association (AMA).  After seeing many of these organizations up close, the DMCB can assure readers that that is where the resemblance ends. Being much closer to the ground level of clinical practice, these entities are acutely aware of the decline in private practice. Many have watched their membership - and their income - go down as the result of docs joining salaried settings where membership dues are a cost and meetings are time away from patient care. As a result of their hunger for business, the state societies have responded in part by making their suite of member services more turn-key and easy to use than ever before.  They have to do that to hold onto their current membership.   

Fast forward the possible bleak future described above. The most expensive part of a hospital system's work force will no longer look quite so affordable.  Some physicians will have their contracts euphemistically non-renewed, while others will be beat up by less "fixed" and more "performance-based" variable salary arrangements.  Since its reasonable to assume that the health reform's malaise will be nationwide, it's unlikely that these disgruntled docs will be able to simply pull up stakes and get hired in some other comfortably suburban setting in the next county or next state.

They'll think about private practice.

They'll wonder if they can start their own businesses, negotiate their own insurance contracts and do so with less overhead and without being told what to do by clueless administrators.  They'll be wondering about finding a practice manager who knows about coding and billing. They'll think about about cutting out the insurer middleman with a cash-only option. They'll think about dropping of out Medicare. And they'll realize that they will probably need to buy "malpractice" insurance and want a quote.

There are many good companies that offer support services to physician-owned practices. They'll get phone calls too, but not like the state organizations. They'll be the first to know.

They'll be the canary in the mine.

And in case you think the DMCB is being a pessimistic weenie, consider this anecdote: decades ago, physician staff unhappiness with one health system's managed care contracting led a renegade group of docs to call a state medical society for help.  The society obliged and participated in a series of after-hours presentations on physician practice that was attended by almost a third of the staff physicians. The young physician DMCB was in the back of that room.

If the DMCB was in the Obama White House, it would advise that it assign one of its health policy interns to regularly call the execs of a number of state medical societies.  If they describe sharp upticks in membership, that'll be cause for concern.

Image from Wikipedia

The Important Look AHEAD (Action for Health in Diabetes) Study: No Benefit from Exercise and Weight Loss in Diabetes?

Diabetes? Exercise and then die just as soon.

It makes sense, doesn't it? If persons are overweight and have diabetes, diet and exercise-based "prevention" should translate into fewer heart attacks, strokes and deaths, right?

Wrong.

It turns out that a just-published and high quality research study shows it's not so simple.  What's more, the Disease Management Care Blog brazenly suggests that the disease management/population health vendors discovered this years ago.

The just-published study is here in the prestigious New England Journal of Medicine. The DMCB suspects that, thanks to the mainstream media's fixation on Snowden, SCOTUS, and Shakira possibly hawking Obamacare, this important research may not get the front-page attention it deserves.  Considering that it was ten-year, prospective, randomized multi-center academic study involving over 5000 patients, that'd be a shame.

Here's the DMCB's summary:

Eligibility: Participants had to be between 45 and 75 years of age with adequately controlled (A1c less than 11) "type 2" diabetes, an "overweight" body mass index (BMI) of 25 or more, blood pressure less than 160/100, an ability to exercise and access to a primary care provider. 

Recruitment: This went from August of 2001 through April of 2004. It was also tailored to keep insulin-using participants to less than 30% of the study group.

Interventions That Were Compared: Participants were randomly assigned to an "intensive lifestyle intervention" study arm or a "support and education" study arm.  The intensive group received weekly group and individual counseling for six months that subsequently tapered over the subsequent duration of the study. The counseling included a 1200-1800 calorie diet plus 175 minutes of moderate physical activity per week that was aimed at achieving a weight loss of at least 7% of body weight.  The support group got only three group sessions per year. Medicines and their doses were generally left to the primary care provider.

Outcomes Studied: Participants' waist circumference, weight, blood pressure, medications and exercise tolerance were assessed once a year. Hospital and other medical records were reviewed to assess the number of deaths and cardiovascular events, such has heart attack or stroke.

The Study Population: 5,124 persons were enrolled; 2570 were randomly assigned to the intensive group while 2575 were assigned to the support group. The average age was 59 years, 60% were women, the median duration of the diabetes diagnosis was 5 years and the average body mass index was a hefty 36. Only 4% were lost to follow-up.

Outcomes:  After a median of 9.6 years of follow-up......

• patients assigned to the intensive group lost approximately three cm. from their waist and six kg. in weight vs. zero cm. and four kg., respectively, in the support group. This translated to a weight loss of 6% of body weight (vs. the target of 7%) in the intensive group vs. about 3.5% in the support group.

• the A1c, which is a test of overall blood sugar control, was about two tenths of a point (7.4% vs. 7.2%) lower (i.e. better) in the intensive group. LDL cholesterol was also lower. Better control of the diabetes meant that the persons in the intensive group were taking fewer medicines at lower doses.

• But it was all for naught.  During the course of the study, there were 403 cardiovascular deaths, non-fatal heart attacks or heart-related ("angina") hospitalizations in the intensive group, vs. 418 in the support group. The calculated rates of 1.8 vs. 1.9 events per 100 person years was too small to be statistically significant and was more likely the result of chance or randomness.

The Disease Management Care Blog's take?

The early painful lesson of the "disease management" industry was that a broad life-style intervention applied to a large group of diabetics was not going to meaningfully improve outcomes. Critics believed that while the interventions were conceptually sound (diet, exercise, weight loss), the delivery was flawed. 

This just published NEJM study would suggest the intervention itself is futile. If so, that is bad news.

"Not so fast!" says the DMCB.

In addition to renaming itself (now "population health"), the industry responded to the science and the critics by retooling.  It learned to channel tailored interventions at population sub-segments who are most likely to experience a specific benefit. Instead of an "intensive" weight loss intervention for all overweight diabetics, population health can use baseline survey, insurance or clinical data to spot (risk stratify) those diabetics who are most likely to achieve a specific benefit that could range from (for example) a sustained 7% weight loss to reduced readmissions.

This NEJM study tried to benefit all diabetics.  A better approach is to find which diabetics will benefit.

As an aside there were some other issues with the study to bring up when debating the study with colleagues and foes:

The BMI of 36 suggests this was a very obese study population that lost only 6% of their body weight during the course of the study.  Since weight was still a health risk at the end of the study, the DMCB wonders if the intervention would have shown more benefit with a less heavy population.

The support group also lost weight and lowered their A1c, which could have obscured the clinically significant benefit in the intervention group. 

This accompanying editorial points out that lower statin and ACE drug use in the intervention group could have paradoxically increased their risk, since these drugs are known to lower the incidence of stroke and heart attack.

The editorial also points out that spin-off studies have already shown that the intervention group benefitted from higher quality of life.

What Can Martial Arts Teach Us About the Health Reform Debate

Despite years of training, the weakling Disease Management Care Blog was never able to prevail in martial arts tournament sparring.  While it might score some points in the early rounds, coming up against a six foot plus 220 lb guy with a kick able to reach Toronto was usually an exercise in Tae Kwon Do humility.

Despite the certainty of defeat, how would the DMCB deal with such superior adversaries? 

One survival technique was to to reduce its profile by standing obliquely sideways.  Both arms were kept up with fists poised on either side of the face and with both elbows on either side of the abdomen.  Since tournament points could only be scored from the waist up, the DMCB found it could block most strikes with minimum arm movement of just a few inches.  Then the DMCB simply waited for Toronto to attack.  Assuming the block was successful, the DMCB would then quickly and sneakily move in while the opponent was pulling back its punch or kick.  That's when he was most vulnerable.

This technique of blocking and then striking on the rebound is not only on ample display in televised cage fighting, but in the sparring over health reform. Whether its modifying the ACA, reforming Medicare or fixing the SGR, the playbook is the same: simply sit tight, await your opponent's proposal and then strike back immediately with a mix of rhetoric, partisanship and invective.

Unfortunately for our Republic, martial arts also teaches us that while that approach may in aid in the short-term survival of weaklings, it's ultimately not a strategy for winners.  The DMCB never got a trophy by hunkering down, and that sparring technique will not create the kinds of thoughtful solutions that can overcome Medicare's cost spiral or the Affordable Care Act's shortcomings.

What wins is initiative, innovation and risk-taking in an aggressive series of proactive moves.  Say what you like about progressive Obamacare or the conservative Ryan Plan, their champions went on the offensive.  That skill not only wins tournaments, it ultimately wins in politics.

Image from Wikipedia

The Prognosis for a Budget Compromise on Medicare Under the Budget Control Act of 2011: Not Good

It sounds reasonable enough.  Across-the-board cuts for Medicare and national defense is such an anathema that the "The 12" Super Committee politicians from both extremes of the ideological spectrum will find some way to reach common ground, right?

Think again. 

That's the message from an eye-opening editorial from a D.C. insider who is laying odds on no agreement and that the automatic cuts will happen.

By way of background, the Disease Management Care Blog checked out this handy Kaiser Family Foundation Brief on the Budget Control Act of 2011.  Briefly, The 12 must present a $1.2 trillion 9 year plan (going from 2013-2021) by November 23.  It must be voted on by December 23 and it must be signed into law by the following January 15.  If no plan makes it past that finish line, the Office of Management and Budget will have to "sequester" (claw-back) already budgeted money equally over each of the 9 years. Half of the cuts will have to come from defense and the rest will have to come from non-defense areas. 

Even if defense and other parts of the budget are reduced by The 12, the math says Medicare (except for Part B and D premiums, beneficiary cost sharing and Part A revenues) would still have to be addressed one way or another. The maximum that could be cut from that entitlement is 2% per year; that would mean a reduction in payment rates.  

That's when providers would go bonkers, health care advocates' blood would boil, hospitals would threaten lay-offs, doomsday attack ads would distract from Dancing With The Stars and someone's grandma will die.  Would our already reviled political class even dare to toy with such Kryptonite this close to a Presidential election?

Former Clinton Advisor Christopher Jennings (who held his own crossing swords with Gail Wilensky on a past PBS NewsHour) writing in the New England Journal, basically says the prognosis for agreement is grim and that's exactly what is going to happen because:

1. All health care stakeholders and advocates already understand what would happen with an across-the-board 2% Medicare cut.  On the other hand, they have no idea what mischief could happen if The 12 dive into the weeds of how the entitlements currently function.  Strangely enough, therefore, they seem to prefer the former,

2. It's very possible that the Republicans could successfully insist on more than 2% in some parts of the program and that the Obama Administration would throw Medicare under the bus agree - if it means getting concessions on the President's yet-to-be-announced jobs plan, and

3. Medicaid is exempted from the process.  An agreement by The 12 would be almost certain to tack on reductions in Medicaid, which could bust a lot of state budgets.

Think a reasoned bipartisan compromise will emerge, based on a Congress that wants to avoid a replay that led to a downgrade and do what's best for the Republic?  Based on the ingredients above, you may be wrong.

Vermont's Single Payer Model: Evolving or Naive?

And so it shall be.....

Newly launched pharmaceuticals and medical devices follow a predictable business cycle. Powered by glowing research reports, there is an initial period of marked enthusiasm and high sales.  Then, as experience accumulates, reports of limited real world effectiveness and side effects unanticipated by all those smart scientists rudely intrude. Sales peter out and the market awaits the next miracle, the next Blockbuster, the Next Big Idea.

Is the same pattern true for health care policy?  Will Vermont’s foray into a “single payer system” fall victim to the same cycle of frothy acceptance followed by bitter disappointment?  Those questions were on the Disease Management Care Blog’s mind when it read Amy Wallack’s self-assured two pager New England Journal perspective “Single Payer Ahead – Cost Control and the Evolving Vermont Model.” 

As the DMCB understands it, the Swedish Green Mountain People’s Republic has decreed that its health insurance exchange (HIE) will offer a “public option” insurance plan that will be designed and funded to drive other insurers out of the state, including Medicare and the military’s health plan, TriCare. Capitalizing on the widespread frustration with fee-for-service provider reimbursement, Vermont will launch a payment system packed with the latest darlings of health reformists everywhere, including “medical homes,” “bonuses,” “quality metrics,” “pay for performance,” ”global payment” and “bundled payment.”  Top this off with an “Green Mountain Care Board” that can set provider fees, deny coverage for unproven “technology” and review competing commercial insurers’ rates, and 650,000 Vermonters will be participating in a cluster of top-of-the-enthusiasm-cycle policy preferences that, until now, liberals and progressives could only fantasize about.
 
Snarkiness aside, thousands of regular DMCB readers know that every one of the reforms described above have not consistently fared well in the real world.  While glossed-over statistics, idealistic generalizations, selective interpretations and a neo-European ideology have convinced much of the political class, the inconvenient truth is that we simply don’t know how this will work out for the patients being cared for by the docs at Vermont’s 14 community hospitals.  It also remains to be seen how a government-run insurer will be any more responsive, cheaper or better quality-wise than a similarly sized not-for-profit health plan – outside of its ability to dictate take-it-or-leave-it prices and hide costs by spreading them out over a tax base.

The good news is that any possible damage will be contained to a single state, versus the slow-motion car wreck that could happen under a similarly contrived one-size-fits-all nationwide plan.  Which is why, in the end, the DMCB is all for Vermont’s foray, just like it thinks the Massachusetts plan was a good idea.  If Vermont’s model works out for its citizen-patients, the DMCB will be the first to congratulate Dr. Wallack and her colleagues on the Governor’s staff for a job well done. 

If not, the DMCB will be there to help think – and be simultaneously cautious - about the Next Big Idea.

Of Downgrades, Treasurys, Sins of Omission vs. Commission, Spin and the Affordable Care Act

The Disease Management Care Blog hopes that when this interview was recorded, Treasury Secretary Geithner was engaging in some "spin" for public consumption and didn't really discount the possibility of a rating agency downgrade when he was working behind closed doors at the White House:



While Standard and Poor's (S&P's) action has been called into doubt because of the agency's past gaffs, the DMCB points out that the mortgage backed security mess was a sin of omission.  In other words, they missed the risk to investors.  However, once they spot a risk, S&P doesn't have a reputation for unnecessary exaggeration.  It remains to be seen if the markets to decide if the downgrade was a sin of commission. 

Which brings the DMCB to the Affordable Care Act.  Do the Adminsitration and its allies really believe this or is this some sort of spin also?

Medicare As We Know It Is Ending Under the Republican and Democratic Proposals

Good bye!

Pssst.  Guess what.  If either the a) the President and his Democratic allies or, b) the resurgent "Path-to-Prosperity" Republicans ultimately win Medicare deficit-funding debate, "Medicare as we know it" is going away.

That's the conclusion of the weary Disease Management Care Blog after reading the text of today's speech by President Obama on reducing the U.S. budget deficient.  More information can be had by checking out this White House fact sheet. 

A previous review of the sweeping Medicare changing Republican Ryan proposal can be found here.  Those are big changes. 

But so are the President's.

In tones that even the New York Times called "partisan," Mr. Obama extrapolated on Congressman Ryan's "voucher" proposal and asserted it will result in "$6,400" in additional out-of-pocket expenses for Medicare beneficiaries. Arguing that it's smarter to reduce the overall cost of health care, the President proposes to instead attack "wasteful subsidies and erroneous payments," leverage Medicare's purchasing power to command discounts and incent doctors and hospitals to prevent injuries and improve results.

Readers may recall that all those audibles are already in the Administration's CMS Playbook. What caught the DMCB's eye was the added proposal to "strengthen" an "independent commission of doctors, nurses, medical experts and consumers who will look at all the evidence and recommend the best ways to reduce unnecessary spending while protecting access to the services seniors need." Furthermore, if "Medicare costs rise faster than we expect, this approach will give the independent commission the authority to make additional savings by further improving Medicare."

That 15 expert member "commission" is a creation of the Affordable Care Act, otherwise known as Independent Payment Advisory Board (IPAB).  It is empowered to bypass Congress with cost-saving changes to Medicare, so long as it doesn't change coverage or quality. What's more, just as the President said, if the changes don't result in actuarially projected savings, IPAB is responsible for generating additional recommendations that must be carried by the Secretary of HHS.  What's new about the President's proposal is that the Board will be charged with striving for even tighter GDP-based global cost targets than previously anticipated.

So, why could Medicare-as-we-know-it end?  Up until now, it has been the style of Medicare to cover all reasonably medically necessary health care services.  In the "real world" of patient care, Medicare beneficiaries - with the exception of some preventive services - get sick and doctors treat and get paid.  Under the Democratic IPAB proposal, it is highly likely that U.S. docs' treatment options will be clinically or economically curtailed to what is officially "evidence-based."  

While that doesn't necessarily sound bad, much of the published science that will underlie the Commission's recommendations simply isn't up to the task.  While certain testing and treatment strategies are superior to others, comparative effectiveness research can be illusory, research results can be less than pristine, outcomes may not uniformly apply to all individuals and they often remain chronically (and thankfully) open to re-interpretation.  Highly trained U.S physicians will wonder - just as they do in their tussles with commercial managed care today - how remote experts use flawed and "succesionist" logic to decide what's best for their patients under their special and unique circumstances.

That's a lot of change.

Even though it's ironic that the solution to CMS' failures to date is even more CMS, the DMCB also wonders if either Congress (with its partisan hearings and tradition of service to constituents) or the Executive Branch (favoring the special interests of key political allies) can really resist the continued political temptation to meddle in a trillion dollar industry.  That won't change.

While this could rekindle the death panel controversy, this could ultimately turn out to be what the President doesn't want: re-run of the 2010 debate over the role of government in health care.  The blogging DMCB, on the other hand, looks forward to a bloggy-target rich debating environment: do we want the enlightened allocation of health care resources or... do we want to harness the wisdom of markets?  Which is worse: top-down central planning or... forcing vouchers on vulnerable seniors and forcing them to choose between eating, heating or healing?  And finally, which party can frame ("vouchers!" or "premium support!") the debate and deploy the best rhetoric (that $6400 is not a CBO number, is it?) to meet their policy and political ambitions?

Happy Anniversary Affordable Care Act

About one year ago, the Disease Management Care Blog was watching health reform unfold in all of its toxic splendor. Deconstructing those complex events will happily occupy pundits, pollsters, editorialists historians and bloggers for years to come. The DMCB likewise hasn't been immune from reflecting on some of the ingredients that were mashed into the dreadful sausage-making that ultimately made up the Affordable Care Act. To wit:

~ an emboldened Democratic Congressional leadership determined to govern from the left of their rank and file;

~ the staking of a U.S. Presidency on a huge roll of the political dice - that could still come up snake eyes;

~ speculative projections from health care economists able and willing to portray any scenario based on assumptions built on theories derived from wishful thinking, which still continues today;

~ organized medicine groups being politically boxed in by a) their prior position statements, b) an bum deal over the SGR and c) fear of being thrown under the bus;

~ the astonishing misuse of 'health insurers" as a political piñata for garnering support, deflecting criticism and changing the subject;

~ equating any lack of support for health reform as a lack of education about health reform.

And how do things stand today? For the best example of how topsy turvy things are, check out the disparate perspectives of some Kaiser report "players and experts."

~ State governments are simultaneously opposing and implementing the ACA;

~ Maybe providers and insurers didn't really need federal legislation to cooperate all along;

~ It's not a majority or any broad political coalitions - which remain stubbornly split - but the small "independent" voter block that may hold the key to the long term survival of national health care reform.

~ The private sector still remains the best hope for innovation.

~ It's in the regulations outside of the legislative process where important battles over the MLR, insurance exchanges, essential benefits packages and worksite wellness programs will be won or lost.

~ The direction of national health reform will be decided by nine lawyers - and probably one in particular.

One question continues to perplex the DMCB: Why is the Administration so reluctant to endorse the eponymous flattery and historical legacy of the term "Obamacare?"

Image from Wikipedia

Modular Approaches to Our Post-Industrial Biologic Age

In a fav Disease Management Care Blog movie Bladerunner, Harrison Ford portrays a futuristic cop who tracks down genetically engineered humanoid "replicants" that have gone rogue. Too bad their emotions and free will get in the way of accepting their assigned tasks, like combat (the menacingly friendly Roy Batty), dangerous work (Zhora and her artificial snake ooo la la) or serving as a "pleasure model" (Goth-like Pris, ably played by sexy-no-more Darryl Hannah).

While there's plenty of theme to go around (so, just what is the definition of "human?"), it's the "modular" portrayal of biology that has caught the imagination of the DMCB. In contrast to the standard sci-fi plot of simply growing bodies, Bladerunner implies the creatures are assembled, Frankenstein-like, from parts manufactured in outsourced mini-labs.

Pretty good soothsaying for a 1982 film. Fast forward to May 2010 and the announcement that that Gibson and colleagues have inserted a new set of chromosomes into the bacterium Mycoplasma mycoides, creating a form of life that is without an ancestor. According to this article in The Economist, Craig Venter and colleagues assembled and combined the necessary blocks ("cassettes") of DNA and then used a virus to insert a newly completed genome into a DNA-free cell host. It started to divide and, well, Life Was Created, sort of.

So what does this have to do with disease management, you ask? The DMCB thinks the imagery of successful 'swapping" of the components of complex organic systems is having a far greater impact on our culture than we realize. At the height of Industrial Revolution, society reflected that Age's principles of scientific rationalism and standardization. Schools were one-size-fits all, soldiers and tanks assembled in huge symmetric formations and everyone lined up for their immunizations.

Since our transition to a post-industrial Information Age, the paradigm has now become more "biologic." DNA can be tasked to computing, complex organizations are referred to as living and Hollywood even portrays entire planets as animated with an interconnected network of life. And in the middle of all that are stem cell infusions, telomere manipulation, immune modulators and solid organ as well as facial transplants. Is it any accident that education is often based in experiential learning guerrilla war has become organic, and population-based health care is based on interdependent care interventions (value based insurance design, physician payment reform, shared decision making, medical homes, disease management and the like?)

The DMCB is out on a limb here, but it's not sure if cultural form follows function or vice versa. But in our age of organic, flexible, interdependent and plug n' play approaches to education, health care (and unfortunately war), it seems scientists, administrators, policymakers and provider organizations that use the same approach to the problems of our modern age are the ones poised to come up with the Next Big Advances. Like creating living cells or, which is just as exciting, reducing the burden of chronic disease.

The Reality of Health Insurance in the Individual Market: Even State Programs Are Increasing Rates

The Disease Management Care Blog doesn't much care for drama that pits white hats against black hats. Novels, plays or movies that portray triumph and tragedy despite our very human flaws are the ones that have staying power because they give us insights about ourselves. Franny's borderline mawkishness, Hamlet's dithering and even Hans Solo's mercenary swagger are the ingredients that can distinguish the serious from the superficial plots. These are the stories that tell us about the human condition and how we deal with our grey world.

Contrast that with other vacuous fictions, like each of us has a marketable talent awaiting discovery by Idol, adolescent vampires routinely sport 6-pack abs and that stand-alone health insurers exist only make huge profits at the expense of the little guy. These simple plot-lines provide a nice fix in a culture addicted to superficial explanations, but little else. What's next, that all that's needed to be President is common sense and conservative values?

Anthem and other health insurers were pilloried ('screw its customers,' or 'defiant and unapologetic') for passing its increases in overall health care costs in a changing book of business to their individual market customers. Yet, for a grey-world reality check, take a look at this report about Pennsylvania's adultBasic program. Run by Pennsylvania's Insurance Department using funds received from the National Tobacco Settlement and through 'voluntary' contributions from the State's 'Blues' plan, it serves as the health insurance program 'of last resort' for indigent individuals unable to obtain insurance elsewhere. Currently, there are just over 40,000 enrollees who pay a subsidized premium of $35 a month, but, due to lack of funding, there is a waiting list of approximately 3500 qualified individuals who pay the full premium of about $330 a month.

Well, thanks to 'sharply rising costs,' persons on the waiting list will see their preimum double to $600 a month. For those already in the adultBasic program, their monthly premium will go up by $1 to $36, but office visit as well as emergency room co-pays are doubling and other services will now have a 10% co-insurance. The reason for these increases in a group least able to afford it isn't because this health insurance program is putting profits before patients, but because:

'...general “medical” inflation: medical appointments and procedures simply cost more than they used to. Another major reason for ... cost increases is that everyone who accesses the benefit package tends to use medical services at a level much higher than in the commercial market. Because of these factors (general medical inflation plus significantly higher usage), the rates needed to be increased substantially to allow the program to continue covering as many people as possible.'

Of course, upon further quiet reflection, smarter folks recognize that it's not the insurers' 'fault,' but a business model that even Republicans agree is broken. Yet like any good storyline, flawed fixes abound: individual mandates to increase the risk pools seem politically unpalatable and do little about the underlying rising frequency and severity of claims expense, while tax breaks and cross border sales could result in a race to the bottom for even fewer people who choose to buy insurance.

This is not easy stuff. Superficial storytelling may make for heros and villains from either end of the political spectrum, but our flaws and the greyness of reality is far different.

A Holiday Reminder

Whatever you may think of Washington DC's road to health reform, the Fat Lady reminds us that we need to put things into perspective. Recall the Fat Lady is the savior in J.D. Salinger's classic Franny and Zooey. Franny is overwrought by the misplaced passions of her time. After considerable struggle and prayer, Franny achieves a newfound insight about what really counts. J.D Salinger wonderfully describes how Franny's anxiety evaporates in the face of knowing What Is Truly Important. She sees the way through and the transcendent Fat Lady is not surprised.

Of course, J.D. Salinger can't take full credit for the metaphor. The Disease Management Care Blog thinks much of the credit goes to an event that occurred 2000 years ago. While Rome was no Washington DC, its citizens were acutely aware of the influence of power, the role of alliances and the struggles that resulted in winners and losers. Little did anyone realize that those temporal ingredients would fade in importance thanks to stunningly new insights on how to deal with the world. All this and much more thanks to a small baby born in a small outpost of the Roman Empire.

The DMCB has been to Washington DC and it's full of statues of dead people. Every one of them did something important and the DMCB thanks every single one of them. It is also thankful to its President and the members of Congress for their efforts on health reform, as well as all the other stuff they're doing. In fact, it wouldn't be surprised if a Senator or two gets recognition with a statue.

However, the Fat Lady doesn't care about that. She is looking deeper at each one of us with a far different measuring stick. This Holiday Season is a good time to pause and be thankful for that gift of insight.

The Core Issues in Health Reform

Want a short summary cheat sheet of the core issues that are likely to be included in the final version of health care reform? Thank Paul Ginsberg's short article in the New England Journal of Medicine. Thank the Disease Management Care Blog for giving you an even shorter summary:

1. Expansion of the number of people with insurance: likely to turn out to be a blend of Medicaid and private market subsidies. All that remains is reconciling the more conservative fiscal considerations of the Senate versus the more generous House version.

2. Individual and small market insurance reform: look for 'actuarially equivalent' insurance options being offered through state exchanges with guaranteed issue and a coverage mandate. Right now, our elected representatives are hard at work reconciling that mandate with the level of insurance subsidies: the tougher the penalties, the higher the subsidy.

3. Purchasing of 'high value' care: the Achilles Heel in all this is the risk that health care efficiency will be increased by sacrificing quality. Time will tell if new versions of capitation, payments per episodes, efforts to reduce Congressional meddling, support for health information technology, comparative effectiveness research and prevention will pay off in bending the curve.

4. Tax increases: right now it looks as if there will be a combination of tax increases for high income individuals (the House version) and taxing high end health insurance policies (the Senate version).

Two other points:

Senator Harry Reid (D-NV) has definitely signalled that the Senate may not pass a bill until after Christmas. This may reduce the prognosis for health care reform, but the Disease Management Care Blog doesn't think that will be a lot.

While it will be up to the Conference Committee to reconcile the House and Senate versions and finally give the DMCB a likely description of what health reform will really look like, much important work will need to be done in writing the regulations, creating the organizations and writing legislation to deal with unforeseen consequences.

In other words, if health reform passes, the real work will have only just begun.

Health Care's Actual Costs Versus Their Reasonable Costs: Insights From the New England Journal

You can't fight City Hall, the State Capital or Washington. Not when it's not 'reasonable.'

Right after an embarrassingly self-promoting and one-sided political treatise by Senator Max Baucus (the link is undeserved, that's how awful this is), there is a far more telling November 5 New England Journal of Medicine article by Wendy Parmet titled 'Litigation Amidst Reform - The Boston Medical Center Case.' It reviews how BMC elected to go to court even as Massachusetts' ballyhooed health reforms were being implemented.

BMC, unlike its more profitable neighbor hospitals, has a mission of treating the poor, the uninsured and, by extension, those with Medicaid. When the State altered the safety net hospitals' payment methodology as part of its reform, BMC decided to sue. It used several arguments: 1) safety net funds that had been previously authorized were still owed, 2) demanding services without just compensation is akin to the taking of property and 3) there is legal precedent that requires that the State meet the hospitals' financial requirements.

Not so says Massachusetts. Its filings in response to the suit indicate that the funds that have been authorized have been paid in full. What's more, they argue that BMC has long agreed to accept Medicaid payment rates - period. What really caught the Disease Management Care Blog's eye, however was another novel arugment from the State: the law only requires that hospitals be paid their reasonable costs, not their actual costs.

Ms. Parmet suggests BMC has an uphill fight on its hands. State courts have been generally deferential to their health agencies in these matters. Many scholars have pointed out that the Constitutional prohibition against the unreasonable seizure of property does not extend to 'services.' Finally, while there was a part of Federal law that required 'reasonable and adequate' payment rates under the 'Boren Admendment,' that inconvenience was repealed years ago.

The distinction between reasonable and actual has been enough to give the DMCB a head cramp. If a course of treatment for cancer 'costs' $100,000, should the reasonable cost or the actual cost be covered? While commerical insurers and their slim 3.3% profit margins may pay a negotiated payment for $100,000 services (which essentially boils down to an actual cost), should a government with sovereign immunity be allowed to define reasonable payment levels? If the government deems a hospital bill as 'unreasonable,' should commerical insurers have the same option? What precisely is the definition of 'reasonable' anyway? Cost of capital and labor plus a small profit margin (like 3.3%)? Or, anything that results in an extension of life at a price equal to or less than consensus opinion? If many insurer-provider contracts are based on a percent of prevailing Medicare rates, what happens if the AMA Relative Value Scale Update Committee turns from being 'fair and accurate' to being 'reasonable?' While the current legislation before Congress has the proposed Public Plan negotiating rates with providers, is there any chance that elements of that will be repealed like the Boren Amendment?

While the DMCB was struggling with this, it turned again to the DMCB spouse for her always unique insights. Pointing out that the DMCB has needs, it asked if its actual or reasonable needs should be met.

Her unhelpful response: there is an important difference between 'needs' and 'wants' and both are only sometimes reasonable.

Who Will Flash Mob the Public Option Like Whole Food Markets? Or How?

The Disease Management Care Blog watched the news about a pro-health reform ‘flash mob action’ that materialized on Sept 29 at the Oakland Whole Food Markets with considerable interest. Disgruntled over that company's CEO John Mackey’s August 11 editorial in the Wall Street Journal, members of the Northern California based and culturally ‘Left’ Brass Liberation Orchestra (BLO) wanted to noisily make known their disagreement. As their bullhorned leader exclaimed in the back aisle, health care is a right and Mr. Mackey is an extremist right-wing hypocrite.

The DMCB recalls reading that editorial. It wasn’t all THAT exciting. It was similar to many of the other just-say-no-to-government-involvement-in health-care opinion pieces that have been appearing almost daily in that newspaper over the last two months. Mr. Mackey, like many CEOs who want to cover health insurance for their employees, was in favor of a) promoting availability of high deductable plans as well as health savings accounts, b) allowing cross-State border health insurer competition, c) repealing benefit mandates that favor special interests, d) enacting tort reform, e) increasing cost transparency, f) reforming Medicare and (and this was a new one) g) using tax forms to enable voluntary donations to help persons without insurance.

What provoked the BLO’s ire was the legal and market basis of his arguments in a paragraph about halfway through. After a careful read of the Declaration of Independence and the U.S. Constutition, Mr. Mackey noted he was unable to find any mention of food and shelter as ‘rights.’ He interprets this to mean that Americans decided long ago that these are really needed ‘services’ that are ‘best provided through voluntary and mutually beneficial market exchanges.’ He argues the same logic applies to health care.

The BLO and its action allies obviously beg to differ. What’s more, they argued that Whole Foods Market’s high nutritional-value products, like good health care, are also being priced out of reach by the same cold market-based logic.

Well done, says the DMCB. What is America without the ability of the BLOs of this world to vex the powerful and make uncomfortable the rich? It’s quite cool that this was done with a horn section and without the kind of bile we witnessed at the infamous August Town Halls. In the end, shopper-bystanders were grinning. Point made.

More importantly, if government dominated health care ever does come to pass, the DMCB is confident that the BLOs of this world will be needed more than ever. Given Medicare’s track record, for example, of denying coverage for potential lifesaving services like virtual colonoscopies, not fully paying for wheelchairs and oxygen, or driving contracting entities into bankuptcy, there little reason to believe that the public option won’t be just as capricious.

But it won’t be so easy. As anyone who has visited the Hubert H. Humphrey Building in Washington DC or CMS’ Headquarters in Baltimore knows, there are security guards posted at all the doors with metal detectors. What’s more, in Baltimore, you need to be on a preapproved list and your car will be get-out, open the hood, open the trunk and open your luggage searched. Unlike just walking in the front door at Whole Foods for a flash mob with instruments in hand, it’ll be hard to get that tuba through, let alone explaining what you’re up to to a Federal Officer.

And don’t even THINK about pulling any stunts at the Jefferson Memorial.