Monday, March 29, 2010

iPad Ships!

For my son's birthday, and to celebrate his surviving surgery mostly unscathed, I ordered out an iPad from that first batch. It is scheduled to arrive on Saturday, April 3. Since the kid's birthday isn't for a few more days after that, I might just have to take the thing on a shakedown cruise myself.

The reason I'm posting this now is to let you know about something somewhat amusing, at least to me. I got the notice just now that the iPad had shipped. Today. From SHENZHEN, CHINA. At least we know where these babies come from. Apparently all the new software is finalized and loaded.

More to follow upon the grand opening of our, I mean the kid's, new toy.

Sunday, March 28, 2010

Ethically Right

The abominable health care bill passed late on a Sunday evening.  I will henceforth refer to the bill as the "Sunday Night Massacre" or simply, the Abomination.

Many state Attorneys General are fighting the thing in court, but I have the sinking feeling that they will not prevail. And so, we must live with this thing as the law of the land. Make no mistake, H.R.3590 - The Patient Protection and Affordable Care Act, is not about helping a poor child or a sick homeless person. No, it is a power-grab by the Social Democrats, a narcissistic romp over the Constitution by our President and Comrade Pelosi, hoping to etch a name for themselves in history as the next FDR, a triumph by the Left as a path toward socialized medicine, and Socialism in general. You won't convince me otherwise. More on this below.

Supporters of the bill fall into two camps: those who honestly (and naively) believe in its virtues, and those who cynically hide behind the purported good it will do to further their political aims and ambitions. I am, however, having a moral dilemma concerning the supposed improvements that are found in the bill, such as the elimination of preexisting conditions as an impediment to being insured, the (feeble) attempt to cover more Americans (whether they want such coverage or not), and so forth. Should I therefore close my eyes to the power grab and embrace the bill? For ethical guidance, I have spent much of my spare moments these past few days trying to find the answers in the Jewish moral and ethical traditions. Frankly, I'm still confused, but we have to start somewhere.

Helping those who need help certainly falls under the auspices of charity, and Jewish law discusses charity in detail. Tzedakah ( צדקה‎) is the common Hebrew term, although the more literal translation of tzedakah involves righteousness rather than charity per se. Depending upon the source, we are to give 10 percent of our income (most say after tax, some say before tax, a few say tax might even be included in the calculus of giving). However, one is not to give until it hurts, since
. . . (N)o one should give so much that he would become a public burden, nor more than twenty percent of his assets even if he would not become a public burden.
Rabbi Moses Maimonides was a great Jewish scholar and physician who lived in Spain and then Egypt in the 12th Century. He is often referred to as the Rambam, an acronym of his Hebrew name. In addition to writing one of the preeminent commentaries on the Bible, the Rambam was known for his philosophical and ethical teachings. His comments about the eight levels of charity are apropos here (I should note that the Rambam was speaking of charity from one Jew to another, but I think the ethical principles apply to the more general situation):

There are eight levels of charity, each greater than the next.
[1] The greatest level, above which there is no greater, is to support a fellow Jew by endowing him with a gift or loan, or entering into a partnership with him, or finding employment for him, in order to strengthen his hand until he need no longer be dependent upon others...
[2] A lesser level of charity than this is to give to the poor without knowing to whom one gives, and without the recipient knowing from who he received. For this is performing a mitzvah solely for the sake of Heaven. This is like the "anonymous fund" that was in the Holy Temple [in Jerusalem]. There the righteous gave in secret, and the good poor profited in secret. Giving to a charity fund is similar to this mode of charity, though one should not contribute to a charity fund unless one knows that the person appointed over the fund is trustworthy and wise and a proper administrator.
[3] A lesser level of charity than this is when one knows to whom one gives, but the recipient does not know his benefactor. The greatest sages used to walk about in secret and put coins in the doors of the poor. It is worthy and truly good to do this if those who are responsible for distributing charity are not trustworthy.

[4] A lesser level of charity than this is when one does not know to whom one gives, but the poor person does know his benefactor. The greatest sages used to tie coins into their robes and throw them behind their backs, and the poor would come up and pick the coins out of their robes so that they would not be ashamed.
[5] A lesser level than this is when one gives to the poor person directly into his hand, but gives before being asked.
[6] A lesser level than this is when one gives to the poor person after being asked.
[7] A lesser level than this is when one gives inadequately, but gives gladly and with a smile.
[8] A lesser level than this is when one gives unwillingly.
The Democrats clearly envision themselves at level two at the least, and would place the rest of us at level eight, having to be forced (by them) to give.

Providing health care for those in need is one form of charity. Some of the sages believe that health care must be offered to all in the community for free, but Rabbi Yossi Grossman of Houston says:
(T)he Talmud clearly states that if I jump into a river to save someone and lose my shirt, then I can subsequently charge them for my losses incurred through the act of kindness. That means there’s no obligation to provide universal healthcare. The obligation is to help indigent people. But if the indigent can afford to pay something, then they are obligated to do so. Healthcare is not an automatic right to everyone who lives in the community.
Judaism, being practical on many things, realizes that there might be fraud in the acceptance of charity, and healthcare would certainly be included, as those of us in the business know all too well:
Judaism acknowledges that many people who ask for charity have no genuine need. In fact, the Talmud suggests that this is a good thing: if all people who asked for charity were in genuine need, we would be subject to punishment (from G-d) for refusing anyone who asked. The existence of frauds diminishes our liability for failing to give to all who ask, because we have some legitimate basis for doubting the beggar's sincerity. It is permissible to investigate the legitimacy of a charity before donating to it.
And further, giving when you know you're being deceived doesn't do anyone any good:
The NIMUKEI YOSEF in Bava Kama (6b of the pages of the Rif) cites the RAMAH who explains that a person who gives charity to one who is undeserving will still receive reward only when the giver is not aware that the recipient is undeserving. When the giver is aware that the recipient is undeserving, then he does not receive any reward for his act. (I. Alsheich)
Now, can Tzedakah be confiscated from someone who doesn't want to give? Well. . . this passage says yes. . .
We have already noted that the courts can enforce payment of tzedakah. . . Rabbenu Tam claimed that only verbal pressure could be used . . . Consequently, the Rashba felt that actual physical pressure could be applied. . . However, the Rambam[10] and the Ran both maintained that Beit Din could actually confiscate property. This would appear to go beyond the normal parameters of enforcing mitzvot.[11]
BUT the following puts this in a very contemporary light:

This concept of "the debt of tzedakah" requires elucidation. It runs counter to our intuitive perception of charity as a moral category, voluntary in nature. Yahadut, however, has a different understanding of tzedakah. The Rambam[13] already noted that the term "tzedakah" is derived from the root "tzedek" - justice, and not from "chesed" - lovingkindness. However, it is clear that tzedakah cannot be understood as a clear-cut monetary debt. . .
In the capitalistic system individual ownership is absolute; charity, therefore, is voluntary. I have no obligation to give charity. I owe the poor nothing. Due to my generous nature or sense of moral obligation, I, by my own volition, decide to offer something of mine to the poor. Within this system it is obvious that categorizing charity as a debt is absurd.

Socialism, on the other hand, would be very sympathetic to such a concept. Even if private property is recognized, the individual as part of society is responsible to society’s demands. He is therefore monetarily obligated to fund society’s causes, which include the support of the needy. Hence we can understand the justice which creates the debt of tzedakah. . .

Although aware that Hashem (literally, The Name, i.e. God, the Lord) granted man private ownership, he nevertheless understood that human legal rights were subject to Hashem’s demands. From the fusion of these two ideas sprang the Jewish concept of tzedakah - tzedek he. From a technical legal perspective one man is giving of his private property to another to whom he owes nothing. However from a more profound perspective the first man actually owns nothing, and is merely granted possession subject to the will of a moral and loving God.
It was these ideas that Avraham (Abraham) discovered and taught to his children. It is this understanding of tzedakah that is unique to the Jewish experience, and is unparalleled in secular universal culture. Furthermore, the appreciation and internalization of these ideas are characteristic of the Jewish people, and are critical in their covenantal march through history. Therefore, the fulfillment of this mitzvah is instrumental in the realization of Jewish destiny.

This socialistic interpretation is not really mainstream, and proper Socialists would be very upset to learn that God in Heaven owns everything rather than the State. Still, it is an interesting perspective.  Fortunately, Judaism does not have a problem with wealth, as long as it is used for good:
The Jewish attitude towards wealth is quite positive. In fact, wealth, peace, and/or long life are rewards from God for obeying God's laws (Leviticus 26: 3-13; Deuteronomy 11: 13-16; Deuteronomy 25:15; Proverbs 22:4). Those that use their wealth to help the poor will be blessed by God (Deuteronomy 15:10; Isaiah 1:17-19; Proverbs 19:17) .
The Talmud (Babylonian Talmud, Taanis 9a) also sees wealth as a reward from God. In a wordplay on the verse (Deuteronomy 14: 22): "You shall surely tithe," the Talmud advises that one should tithe in order to become rich (the Hebrew word that means to tithe is very similar to the word that means to become rich). The verse (Proverbs 11:24), "There is one who scatters and yet is given more" is interpreted by many of the commentators (e.g., Rashi and Ibn Ezra) as referring to one who spends his money on the needy. The question of what a person should do to become rich is discussed in the Talmud; one answer is to engage in much business and deal honestly (Babylonian Talmud, Niddah 70b). Wealth is seen as "comely to the righteous and comely to the world" (Babylonian Talmud, Avot 6:8), and affluent people who used their possessions to help others were respected by the Talmudic sages (Babylonian Talmud, Eruvin 86a).

And, the Talmud tells us not to be jealous of others' success:
The rabbis decried envy and jealousy, in which a person, out of discontent with his portion, begrudges the good fortune that has come to others. Envy and hatred of one's fellow-man were cited by the rabbis as vices that "take a man from the world." One of the rabbis was accustomed to offer a daily prayer: "May it be acceptable before Thee O Lord my God and God of my fathers, that no hatred against us may enter the heart of any man, that no hatred of any man enter our heart, that no envy of us enter the heart of any man, nor the envy of any man enter our heart …"
Judaism also is a strong advocate for preservation of life. So what about our obligation to save someone? How far must we go? From Rabbi Chaim Steinmetz:
The Talmud (Bava Metzia 62a) discusses the case of two people who are traveling the desert and only one of them has sufficient water to survive. Ben Petura is of the opinion that it is better that they divide the water and both die, rather than have one watch the death of the other. Rabbi Akiva is of the opinion that "your life comes first", that the owner of the water must save his life first, even if the other person will die. Rabbi Akiva's opinion has become the Halachic (Orthodox Jewish law) consensus. While it is clear that one may not sacrifice his life to save the life of another, there is some debate if there is an obligation to save lives when it will endanger the bystander. The Hagahot Maimoni (Rotzeach 1:14) is of the opinion that it is obligatory for the bystander to place himself in uncertain danger in order to save the victim from certain danger. Others argue that it is forbidden to do so, and that the principle of "your life comes first" applies to uncertain danger as well (Radvaz in Pitchei Teshuva YD 157:15). Based on this opinion, some authorities forbid a donor from giving a kidney to dying patient if it will place the donor in some danger (Tzitz Eliezer 13:101; Minchat Yitzchak 6:103). Rabbi Moshe Feinstein takes a middle point of view. It is not obligatory to place yourself in a situation of questionable danger to save another person's life; However, you may choose to take this risk in order to save a life. Therefore, he rules it is permitted to donate kidneys, even if there is some danger to the donor. (YD 2:174)
Life is precious, and is to be preserved, but how does Judaism deal with the sad fact that our means to do so on a very wide scale are limited? From a 1993 position paper by the United Synagogue of Conservative Judaism:
The Talmud (Sanhedrin 73a) requires the bystander to spend money in order to save lives. If the victim has money, he must repay those who save him (Rosh Sanhedrin 8:1). However, the bystander has an obligation to spend money even when the victim cannot repay. The Chofetz Chaim rules that the bystander is obligated to spend all of his money (Ahavat Chesed 2:20). One reason he gives is that when the Rabbi Akiva states "your life comes first" it implies that only your life comes first; your money does not. Rabbi Yoseph Shalom Elyashev disagrees, and says that the bystander does not have to give more than a fifth of his wealth to save a life (Quoted in Nishmat Avraham V, CM 426:1). He interprets Rabbi Akiva's statement differently, and argues that Jewish sources consider a loss of wealth as a partial "death". Therefore, the donor would not be obligated to impoverish himself to save the lives of others.
Distribution of Scarce Resources -- We have seen that Judaism places a premium on human life and health and mandates the creation of structures to provide every member of society with access to adequate health care. In situations of scarcity, Jewish insistence on the intrinsic and fundamentally precious value of human life makes triage decisions difficult. Consequently, the rationing of scarce resources in the classical texts is often decided on procedural grounds (e.g., first-come-first-served) rather than substantive considerations (e.g., who is worthier of being saved). [Maimonides, Hilkhot Yesodei HaTorah 5:5-7; Bava Metziah 62a]

Recently, Jewish scholars have begun to argue that the cases in the classical sources, which deal with distribution issues among a small number of people, may not be appropriate models for decisions about our society's overall health care system. While individuals are bidden to make all efforts to save human life and forbidden to engage in evaluation of whose life is more worthy to save, Jewish law does recognize limits to the community's capabilities and offers possible models for the limitation of extraordinary expenditures that threaten to impoverish society.
One such model is discussed in the Talmud in regard to how much a community is required to spend to redeem captives. The Shulhan Arukh states that "There is no greater positive commandment than the redemption of captives" (Yoreh Deah 252:1). Nevertheless, the rabbis decreed that captives should not be redeemed for excessive ransoms, "to prevent abuses" (Gittin 45a). At least one opinion in the Talmud suggests that this decree was made in response to the extreme financial burden placed on the community. . .
In these circumstances, we are at least permitted, if not commanded, by the sources on siege to desist from aggressively treating those whose lives we have little chance to save (specifically, the terminally ill) so that we can turn our energies and resources to saving those we can. Specifically, if we were to order our health priorities according to the Jewish demand to afford health to as many of society as possible, the order of services a community should provide would probably be something like this, in descending order of importance: (1) sufficient food, clothing, and shelter for everyone; (2) preventive care in the form of immunizations and health education; (3) treatment of acute and life-threatening, but reversible illnesses; (4) medical care for illnesses, whether acute or chronic, which are treatable and not life-threatening; and, finally, (5) treatment of irreversible, life-threatening illnesses.

It is not fair to ask physicians to make these decisions; they must focus on benefitting the individual patients for whom they are responsible. Moreover, the burden of giving up access to scarce therapies cannot legitimately be put on the shoulders of individual patients; society as a whole must determine when it will provide a given type of medical care and when not. Indeed, Jewish sources indicate that while individuals may devote all of their own resources to an attempt to save their lives, however unlikely the chances of success, a community must be more circumspect in its allocations, taking into account the welfare of all of its members ....

(W)e must face the fact that we are not God, but human beings, with limited medical abilities and limited resources.
As an aside, the article notes:

While physicians are not required to provide their services for free ("A physician who takes nothing is worth nothing" -- Baba Kamma 85a), communal subsidies matched by reduced rates for poor patients have been the norm. [Shulhan Arukh, Yoreh Deah 249:16; see also Responsa Ramat Rahel of Rabbi Eliezer Y. Waldenberg, sections 24-25]

Finally, a word about personal responsibility from the Jewish perspective. Rabbi Hillel, who lived in Jerusalem around the time of King Herod, tells us in one of his most famous tracts (Avoth 1:14):
"If I am not for myself who will be for me? Yet, if I am for myself only, what am I? And if not now, when?"
There are many ways to interpret this, but it seems to represent a balanced approach to life. We must be for ourselves, we must take care of ourselves, we must rely upon ourselves. But we must not think only of ourselves.

With that preamble, it's time for me to try to figure it all out. Judaism does clearly call for helping those in need, especially the sick, and all are commanded to provide tzedakah to fund the effort, according to their means. I could stop there, throw up my hands, and give in to the inevitable, assuming that the Democrats/Leftists are guiding (forcing) me to do my duty to my fellow man. (I might as well start loving Big Brother in the process.) But I think there is a little more to it than that.

Few know all of what is in the health care bill. I've tried to read it, but the legalese is so dense as to render the Abomination completely uninterpretable.  We have been told it will somehow obtain insurance for 30 million Americans, while decreasing the deficit. I think it is incredibly likely that this is a stepping stone to a single-payer, government run system, which will be put in place on an emergency basis when the current plan falls flat on its face.

I have a number of problems with where we are headed.

First, of course, is the fact (and it is a fact) that this bill has no intention of helping anyone but the Social Democrats, who know that once government controls health care, it quite literally controls the lives of its constituents. You can stand on your head and whistle Dixie until the cows come home, and you won't change my mind on this. The Sunday Night Massacre is just the beginning. Liberal columnist Ezra Klein gloats over this certainty and Leftist victory:
But the fact of it is that this bill represents an enormous leftward shift for American social policy. It is not, in my view, a sufficient leftward shift, but it is unmatched by anything that has passed into law in recent decades. Progressives have lost some very hard battles but are on the cusp of winning an incredibly important war. For all its imperfections, health-care reform itself is deeply, deeply progressive. And if you don't believe me, just ask the conservatives who have made opposing it their top priority.

I am very uncomfortable with the targeted, confiscatory nature of the taxes that supposedly fund this little exercise. While we are all commanded to give tzedakah, the targeting of the "rich" is clearly designed to share the wealth, and not the responsibility. This is totally counter to the spirit of tzedakah as described. Of course, those who think they are immune from the costs of the abomination are in for a rude awakening. A T and T, for example, has claimed a $1 Billion charge in the first quarter of 2010 to pay for its share of the new health care costs. Do you think for a minute that won't be passed on to the consumer? You folks out there who are celebrating Mr. Obama's "gift" of "free" health care are about to get a big surprise, courtesy of the Law of Unintended Consequences.

In addition, we are commanded not to impoverish ourselves so as to give charity. Because I have been a little frugal, and saved something over the years, the slashing of my income and raising of my taxes won't impoverish me or send me onto the public dole, but I can't say that for others. But again, the goal of all this is redistribution of wealth, and I suppose many out there would be happy if we could all be equally miserable.

The concept of personal responsibility is defeated by the ultimate goal of the Patient Protection and Affordable Care Act. Maimonides told us that the greatest level of charity is that which "strengthen(s) his hand until he need no longer be dependent upon others." This bill has just the opposite in mind. Ultimately, this offers a "hand-out" and not a "hand up". The Left, Democrats or not (and not all Democrats are Leftists), has a significant degree of antipathy toward personal responsibility. In their Utopia, everyone would be able to do their own thing without regard for the consequences thereof. Don't believe me? Read the words of Comrade Pelosi herself:
Think of an economy where people could be an artist or a photographer or, eh, a writer without worrying about keeping their day job in order to have health insurance, or that people could start a business and be entrepreneurial and take risk but not [be] job-locked because a child has asthma or someone in the family is bipolar. You name it. Any condition is job-blocking.

This certainly sounds magnanimous, doesn't it? . Going a bit deeper (and I'm going to make a lot of you angry with this one), this reveals the deeper desire to decouple results from actions and intentions. The Left does this well. Having indiscriminate, unprotected sex? Let's have abortion on demand to fix the potential result (an attitude you will recognize no matter what side of that debate you are on). Your child doesn't want to work hard in school? He should get an "A" anyway for simply showing up to school, or maybe grades should be eliminated altogether so little Fauntleroy doesn't feel bad about himself. You would rather spend your money on an Escalade (or payments thereof), $200 tennis shoes, and an iPhone with $100/month service than insurance? No problem, we'll take the money from the "rich" to pay for your health care. Oh, and by the way, feel free to smoke, drink, take illicit drugs, participate in dangerous sex practices, and so forth, even though that might affect your health. This is clearly counter to the self-reliance taught by our Sages. And don't forget, we are not to give charity to those who are undeserving.

Let's remember the words of the Rambam once more, ". . .(O)ne should not contribute to a charity fund unless one knows that the person appointed over the fund is trustworthy and wise and a proper administrator . . ." Do we really trust the government to oversee this massive entitlement program? Do we really trust Comrade Pelosi and Big Brother and a sea of nameless, faceless bureaucrats to make our health care decisions for us? Keep in mind, there WILL be rationing of some sort, as this bill will have unsustainable costs. Believe it, even in spite of the lies about its being revenue neutral or even deficit-reducing. That myth is borne of some budgetary sleight-of-hand which shifts dollars away from the massive Medicare entitlement we already have. Someone has to pay, and that will be us, patients and physicians. I submit that the free market, properly regulated, would do a better job. Customers would flock to the insurance policies that give them the best coverage for the most reasonable, if proper regulation allowed them to do so.  The scope of this already too-long post does not allow an adequate discussion of what needs to be done with and to the insurance companies.  Suffice it to say that I find them neither friend nor enemy.  They are in business to make a profit, and the laws must guide them toward doing so in the manner that benefits their customers, the patients, to the greatest extent.  That does not mean hamstringing and gutting them so they will go out of business, "forcing" the government to take over completely. 

And what of our duty to the poor? We must take that very, very seriously. But wait, most physicians already do. My group, for example, eats millions of dollars in "Self-Pay" coverage, and if you didn't know, "Self-Pay" generally means "No-Pay". This is a cost of doing business at the big hospitals, true, but it is the right thing to do. Why do we never hear about the generosity of the average doc in the media? Because that wouldn't further the Leftist agenda, now would it? Forcing physicians' fees through the floor as well as boosting our taxes carries the likelihood of driving many of us out of business, if not into poverty outright. We are commanded against giving until it hurts in this manner.

Finally, as I have described in an earlier post, artificially fixing the prices on health care will stifle innovation. This will certainly harm many patients in the name of "helping" others, again counter to tradition. The CBO actually agrees with me to a significant extent:
Given the central role of medical technology in the growth of health care spending, reducing or slowing that spending over the long term will probably require decreas­ing the pace of adopting new treatments and procedures or limiting the breadth of their application. Such changes need not involve explicit rationing but could occur as a result of market mechanisms or policy changes that affect the incentives to develop and adopt more costly treatments.  

The vast majority of my Jewish brethren voted for Mr. Obama, and favor the abomination of a bill. Dennis Prager, in his article, "Jews and Big Government," helps us to understand this:
But the reason for their support goes deeper than a desire to see more Americans insured. Those of us who opposed this plan also want to see more Americans insured.

The deeper issue, as President Obama has acknowledged, is the size of government. On CBS’ “Face the Nation” last fall, Obama said, “What’s driving passions right now is that health care has become a proxy for a broader set of issues about how much government should be involved in the economy.”

Exactly right. Jews and other Americans on the left believe deeply in the state as the greatest single force for good in society. Those of us not on the left fear the state’s growth.

Why Jews believe so deeply in the state is a real puzzle. It is not as if the powerful state has been a friend of the Jews. If Jews were often persecuted and killed by religion in the Middle Ages, they — not to mention many millions of Chinese, Koreans, Cambodians and Rwandans — were persecuted and slaughtered en masse by the (secular) state in the 20th century. . .

But none of this matters to most American Jews who hold liberal/left views as strongly as believing Christians hold Christian beliefs or Orthodox Jews hold their beliefs.

Do read the whole thing.

Norman Podhoretz, in his new book, Why Are Jews Liberals? says the same thing, noting that today's Leftist Jews have replaced the Torah with liberal doctrine.
The first half of the book reviews centuries of history and acknowledges that Jews learned that oppression and danger tend to come from the political right. The second half focuses on the shift Podhoretz believes has occurred, particularly since 1967, with the Right becoming more supportive of Israel and of Jewish interests, while the Jews refuse to follow their own self-interest, financial or otherwise.

And it’s not just that Jews are not voting with their pocketbooks, he said, as other immigrant groups tended to do after they “made it” — Jews are also not voting for their own security, particularly with respect to Israel.

“After ’67,” Podhoretz said, “the Left became more and more hospitable to ideas hostile to Jews, particularly on the issue of Israel. It grew more and more anti-Zionist and as time went on, the anti-Zionism became less and less possible to distinguish from old fashioned anti-Semitism.

“But American Jews refused to recognize this great change,” he said.
Jews thought, correctly for the time period, that liberal policies, ultimately including Socialism and Communism, would knock down old barriers placed by Christian monarchies and empires, allowing them (us) to be equal citizens at last. This may have been briefly true, but perhaps no one ever envisioned a place like America where there is no monarchy, no discrimination (OK, that probably isn't true even yet, but we're getting there, and discrimination is totally illegal), and at least in theory, equal opportunity for everyone. Jews have thrived and prospered here in America more we have anywhere else and at any other time in history. But we are now hoist by our own petard for our leftist leanings. In the process of researching this article, I landed upon dozens of White Supremacy sites, whose disgusting content I won't legitimatize by providing links, which blame Jews exclusively for Socialism and Communism, and even the Sunday Night Massacre. Oy vey. . .

After all this, I'm convinced of a few things, though I still have a number of misgivings on all sides of the issue. I know deep in my soul that Washington's approach to health care is morally wrong. It is a power-grab, a plot to redistribute wealth, a scheme that will ultimately fail and take the economy of the nation with it, and possibly nation itself as well. Based on Jewish teachings, we DO have the moral imperative of caring for the sick, and we do accomplish that. I certainly acknowledge that those of us in health care, as well as the average man and woman, can do far better, as far as helping more and giving more. Keep in mind, though, the recipient has a duty as well, to care for himself, to take responsibility for his actions.

Our statist-oriented, Left-leaning government, does not seek any moral, ethical solution to this (or any other) problem, they simply want more control and more power over us. And in your hearts, you know I'm right.

Friday, March 26, 2010

Yup, That's Why We're Upset

It matters, you know. 

Give 'Em The Finger(s)!

From China Daily/Reuters via FoxNews:  
An X-ray picture shows the hands of a 6-year-old boy at a hospital in Shenyang, Liaoning province, China. The boy, who has 15 fingers and 16 toes, was scheduled for surgery March 23, 2010, to remove the extra fingers and toes, local media reported. 

Thursday, March 25, 2010

A Nice Note From An Imaging Advantage Fan

Someone from Saint Paul, Minnesota who stumbled on my blog by searching for "Imaging Advantage" left the following lovely comment on a post from 4 years ago:
This Doctor Dalai blog is a bunch of crap put up by some dumb radiologist who has learned some HTML tagging in his spare time. Get a dang life, doc. And you hide behind Domains by Proxy. Loser.
My first thought was to wonder what Mr. Hashim was doing in St. Paul, but perhaps this is from one of the telerad minions.  In any case, I have the same degree of respect for you and for your presumed employer, Mr. Anonymous, as you have for me.  If you need to get in touch, clearly, I'm right here.  You may feel free to comment, and know that I'm receiving your excretions.  I promise to publish the more amusing entries.  As always, please feel free to create your own blog if you think you can produce something more amusing.  What can we say about someone who wastes 35 minutes and 21 seconds reading the rantings of a "loser"?

Monday, March 22, 2010

Let The Games Begin

If you thought there would be gratitude amonst those who will benefit from the new healthcare abomination, guess again.

I'm working today at our local trauma center.  My interventional colleague just walked into the reading room white as a sheet.  It seems he had the following exchange with a patient:

Doc:  Hi, I'm Doctor X and I'm here to do your procedure.  Please sign the consent form so we can begin.
Patient:  Lemme see that.  (Reads for 5 minutes, then signs.)  I guess you docs got yours yesterday, huh?
Doc:  (silent)
Patient:  Hey doc, you married?
Doc:  Yes
Patient:  I'm gonna send a bunch of (stated minority group) over to your house to take care of your wife!

An abberation?  Maybe.  But maybe this is a bit of insight into how we are viewed by at least some of our patients, as well as the public in general.  Rich guys who "got ours" courtesy of Congress.  You're certainly welcome for the care we've been giving you folks for many, many years.

Sunday, March 21, 2010

Paying the Bill

In June of last year, Dr. Pat Santy, writing in her blog, Doctor Sanity , declared her disgust with the healthcare bill, which now seems to be placed firmly about our necks.  I can't say it any better than she does below: 

I'm done.

My entire professional life as a physician and psychiatrist I have been exceptionally vocal about the prospect of government medicine here in the US. I have given impassioned speeches (when I was younger); written essays in medical journals and elsewhere; and talked until I am blue in the face to anyone and everyone about the horrors of socialized medicine and government interference in the health care system of this country. Once it would have seemed impossible that I would ever want to quit medicine; to stop practicing psychiatry.
I have watched with dismay as every year we have inched closer and closer to the Democrats and the left's goals; goals which I firmly believe will completely destroy American medicine. I have watched up close and personal the utter soul-destroying consequences to both patients and doctors alike, of the pervasive cultural collectivist and looter thinking in my specialty. Every time this madness is killed, it just doesn't stay dead. Like some kind of putrefying zombie, the left just keeps resurrecting it. Logic doesn't matterFacts don't matter.

Let's face it. To the zombies of the left, reality doesn't matter. With President Postmodern in office, aided and abetted by zombie hordes in Congress; why should I pretend anymore that it does?
This time around, I JUST DON'T CARE ANYMORE. If that's what people want, so be it. 
I'm done. If Congress passes Obama's destructive zombie health plan in any form, I quit.
I will simply not practice medicine anymore. I will take my psychiatry books and my years of experience and do something else. I used to wait tables when I was in college. It's an honest living and Obama isn't interested for the time being in nationalizing restaurants--yet.=
Let me be clear. I don't believe that people have a "right" to health care; because, what advocating such a "right" basically means is that you believe you have a "right" to my mind; you have a "right" to my professional competence; i.e., you have a "right" to enslave me.

Having chosen to work primarily in the public sector most of my life, I have watched this entitlement and victimhood mentality grow to incredible proportions in parallel with number of laws, regulations, administrators, and oversight agencies. I have watched the decline of personal responsibility and the rise of endless demands and impossible clinical and psychosocial conundrums that I am expected to solve, even if my patient has no desire to change. I have been demoted to the near-mindless activity of pushing pills to the point that I understand why my collegues see every clinical situation as a biological malfunction--the old adage that says, to a hammer everything looks like a nail, comes to mind. Psychiatrists are the mental health profession's hammer; and drugs are the nail. And, the same powers that tell me to prescribe drugs, warn me against the evil of working too closely with any of the drug companies, for fear I might be corrupted, God forbid, by the dastardly profit motive.
I have watched as the quality of care has inevitably deteriorated even as spending went up. I have watched the system abuse patients and doctors alike--to the point that the frustration level just keeps going up and is simply not worth it anymore.
I quit my memberships in the AMA and APA some years back when I realized that they were not really in it to make things better for doctors or patients. Perhaps at one time they were real advocates for both, but now they are like most of those supposedly "capitalist" businesses--like AIG and all the others-- who willingly feed at the government trough and can't get enough of that yummy government pork. They sold themselves long ago--in both areas of clinical and research medicine-- in order to have a place at Big Government's table....
We will all see what happens when and if the zombies take over health care in this country and make it all like Medicare and Medicaid....and GM and Fannie Mae and etc. etc. 
I expect a Zombie Health Czar (Barney Frank would be perfect) will be appointed any day now. Someone who will have control over doctors' compensation and drug company profits. Someone who won't have to answer to the public who can control implementation of any aspect of the zombie plan that needs to bypass intelligent scrutiny.
Even with the vote, it isn't quite over yet.  Many state Attorneys General (including ours here in South Carolina) plan to fight this monstrosity on the basis of Constitutionality.  It is felt that the Federal Government does not have the right to force citizens to purchase a product, any product.  We will see.  

Friday, March 19, 2010

Unruly Customers

There is a nasty old limerick that begins, "I have no aversions to mergin's with. . ." which is all I can repeat on this family-friendly blog.  Well, I do have some aversion to, well, really fear of, AMICAS mergin' with Merge.  As a loyal and vocal customer of AMICAS, I need to hear that the AMICAS product line will continue unscathed, which means that the majority of the development team and management will be kept on as well. 

No doubt AMICAS never discussed my presence in the Blogosphere with Merge.  That might have scuttled the deal right then and there.  Just ask GE and Agfa if they enjoy basking in my reflected glory and attention.  But its up to the buyer to perform due dilligence and discover these little glitches, and certainly the financiers at Morgan Stanley had the same obligation.  I wasn't hiding anywhere, guys!

Merge has returned to viability, if not yet profitability, under the stewardship of Michael W. Ferro, Jr., Chairman and CEO, Merrick Ventures, LLC, owner of Merge, as well as Justin C. Dearborn, CEO of Merge itself.  These are smart, successful guys.  How smart and successful the lenders at Morgan Stanley are remains to be seen, but one would think they wouldn't release $250 Million without some chance of getting it back with interest.  (Of course, this nation just experienced an economic meltdown due to the government forcing lending institutions to give out cash to people that couldn't possibly pay it back, but I digress. . .)

According to, AMICAS has 250 installations at over 500 facilities. Centricity PACS is installed globally, with over 1000 sites (although none to my knowledge are running the IntegradWeb product purchased several years ago). Fusion RIS/PACS has 200 installs, and Agfa IMPAX has more than 400 sites worldwide.  For those who weren't aware, Fusion is the descendant (and I don't know how much it has been changed since then) of the old eMed Matrix PACS. 

Historically speaking, Merge bought eFilm in 2002, then RIS Logic in 2003, creating their first integrated RIS/PACS.  Meanwhile, Cedara bought eMed in 2004, and then merged with Merge in 2005.  From 2006 through 2008, Merge experienced "corporate reorganizations and restatements", and then "returned to profitability" when Merrick invested in it in 2008.  This is a reasonable pedegree, not all that different from AMICAS as outlined here.  But today, we have Merge with a smaller PACS base and significantly less capitalization buying up its larger competitor courtesy of a very large loan. 

Potential PACS buyers, at least those who do their due diligence, often stumble on this blog looking for ideas as to what to buy or what not to buy.  I don't have any illusions about my ability to influence anyone, but as the lone radiologist PACS blogger, I do get some minor degree of attention.  As such, and as a customer and user of AMICAS PACS since 2004, I have strongly favored and advised its purchase.  But, with the current state of affairs, I have to put that ON HOLD for the moment.  We MUST hear something about the new owners' intentions toward their new acquisition.

If Mr. Ferro or Mr. Dearborn should feel so inclined to comment, this is what I would like to hear:
  • Merge will continue the support and development of AMICAS PACS and other software, without increasing fees to AMICAS users, making AMICAS PACS the flagship product of the new company.
  • Merge will keep the AMICAS development team intact, and as much of management as is possible in this situation.
  • Merge will continue to support AMICAS' Emageon customers, while offering them an upgrade path to AMICAS PACS, again without increasing fees.  The upgrade path should require minimal cost (unlike the potential path to Centricity IW if it ever really happens).
  • Ditto for Merge's own Fusion users (I try to be fair in these things).
  • Merge will find ways to integrate the other products in its portfolio with AMICAS PACS.
  • Merge will change its name to AMICAS-Merge, or at least to Merge-AMICAS. 
I realize this whole merger business was borne of a desire to maximize stock-prices, and as an avowed Capitalist, I must approve.  However, as physician using AMICAS PACS, I have to get up on my bully pulpit (which is definately full of bully) and make these statements/requests/demands on behalf of all of us AMICAS customers. 

Now we see why the AMICAS Board of Directors failed to include me in their portfolio.  Nothing worse than an unruly customer with a blog.

Wednesday, March 10, 2010


Dalai's note:  This is another (master)piece by Mike Cannavo, the One and Only PACSMan, who kindly allowed me to cross-publish it on my blog, further evaluating the Merge purchase of AMICAS. 

There is nothing worse than being all dressed up with no place to go. That is how I felt when I stood by my phone waiting for it to ring with Morgan Stanley on the other line. “Tell us all you know Mike…” and I would share my years of knowledge with them. But alas, twas not to be. After all I am but a lowly PACS consultant with over 25+ years experience in this market while Morgan Stanley is a multi-billion dollar enterprise who knows it all…or so they think…And, hey, if the investment doesn’t work out, well there are always the Feds to help with a bail out as well. Spend my tax dollars well why don’t cha? The Dalai is also patiently waiting for Jason Dearborn’s call…or Michael Ferro’s or any of the others at Merrick Ventures who pull Merge’s puppet strings there too, but he too has heard nothing but Simon and Garfunkel’s Sounds of Silence…

Now before I go on please know that I love AMICAS as a company- its people, its product and its leadership. I also have a great deal of respect how Merge has managed to pull off this “deal” as well. But who is this deal right for- the investors, the companies and its employees, or the end users? As so many have said before, it’s ALL about the money so the answer is glaringly obvious.

Any time a company gets bought by another company in the same marketplace both companies tend to suffer. This is a historical fact. It usually takes 18-24 months before the market is confident enough in the “new” company to buy its products again, and in the interim sales tend to suffer the most. Both companies in this deal should know this all too well from experience with Merge’s purchase of e-Med several years back and AMICAS’ fairly recent purchase of Emageon. Dynamic Imaging also went through this identical scenario when they got scooped up by the folks at Generous Eclectics…and the list goes on and on.

Those end users looking to buy a PAC system are usually very hesitant to buy a product not knowing if the product will indeed live or die. In this situation there simply isn’t room in one company for two competing products. In both the Merge and AMICAS prior deals one product lived and one product died even though the company’s posture might be to say that the best features of both products were consolidated into a single product. Trust me here on this one- one lived, one died.

This isn’t unique to healthcare by any means. Just look at the automobile industry if you doubt this is true. In US Congressional hearings on December 2, 2008, General Motors announced its intentions to focus on four core brands (Chevrolet, Cadillac, Buick, GMC)), with the sale, consolidation, or closure of Saturn and the remaining brands ( Pontiac, Hummer and Saab). General Motors Chairman and former CEO Rick Wagoner announced during a news conference on February 17, 2009 that Saturn will remain in operation through the end of the planned lifecycle for all Saturn products (2010–11). Then General Motors announced in June 2009 that it was selling the brand to Penske Auto Group. On September 30, 2009, Penske terminated its discussions with GM to acquire its Saturn subsidiary after the company's board rejected plans to take over production of the Saturn line. This left GM with no alternative but to shut down the division and close dealerships by October 2010. So much for the “planned lifecycle”. And so much too for Saturn sales. They can’t give them away…

The same thing happened with GM’s Hummer Division. In June 2009 GM announced the sale of the division to the Chinese. By February 2010 the deal was pulled off the table, ostensibly because the automobile “wouldn’t be in line with Beijing’s aim to promote greener cars.” Um…didn’t they know back in June 2009 that the Hummer was no Prius? Someone’s getting a Hummer here, but it sure isn’t me…

Now let’s look at Merge and AMICAS company's revenues (or lack thereof). In FY ’09 Merge had a net income of just $300K on $66.8M in sales. While they could come back and say their adjusted net income was $11.5M I don’t buy non-GAAP adjusted measurements and frankly given Merge’s history with “adjustments” I am a bit hesitant to look at anything but the bottom line. In 2008 the company had a $23.8M net loss ($8.2M “adjusted” loss) on $56.7M in sales. So doing basic math over the past two years Merge has made $123.5M in sales and managed to lose $25.5M in the process. Even if I were to give them the benefit of the doubt and use their adjusted positive net cash number they made a mere $3.3M or a 2.7% net margin…Certainly sounds like a $200M loan candidate to me..

AMICAS was supposed to present its year end financial report February 18, but this keeps getting pushed back, no doubt because of all the scenario related to its pending purchase. The latest financials from 2008 show AMICAS lost over $30M on sales of just over $50M so they aren’t exactly setting the world on fire either. What is even worse is that over 79% of their revenue comes from maintenance and services and just under 21% from software sales. In a comparison of the five year cumulative return as found in AMICAS 10-K filing $100.00 invested in the NASDAQ would show a return of $80.47, the same $100.00 returning $95.44 for the Russell 2000 index while AMICAS would have returned a whopping $37.78. Yessirree sign me up today!!!

So here you have two companies who are hemorrhaging money hand over fist joining forces and no one knows what products from each company will live or die. And no customer- at least no customer in his or her right mind- will buy from either company until they are sure the product they choose is indeed the one that lives and doesn’t die, despite reassurances by both companies to the contrary. Let’s face it- greed is good- and it’s all about the almighty dollar here. Both companies also can’t sustain dual ongoing research and development costs, dual sales forces and management teams, offices in two geographically diverse locations, etc. As soon as AMICAS bought Emageon the reality of consolidation hit the people at Emageon hard and heavy. I would venture to say the same will hold true here with AMICAS unless, and this is a very real possibility, that Merge already has a buyer lined up for some or all of AMICAS’ offerings. I would tend to say this is more than a distinct possibility, but then what do I know…

The Merge people aren’t stupid- they are money men, plain and simple, and this play is all about the bucks. If Merge says we are going to use the AMICAS PACS instead of the Fusion and e-Film solutions solution what does that say about Merge’s PACS offering? Hey, we offered you a lousy solution before but we’re making it up to you by buying you a better one? Or if Merge Fusion and e-film solutions become the PACS solutions of choice from Merge what does that tell the AMICAS end users- we win, you lose- just deal with it? Ugh. This gives new meaning to ugly. This also just what the economy needs- more people out of work- and just what I need too- more out of work sales reps playing PACS consultant until they can find a real job.

This is why I liked the Bravo solution. It got AMICAS out of the public eye, gave them a few years to streamline the operation without having to worry about the bottom line, and then allowed them to come back a lean mean fighting machine with even more solid products than they have currently. They have a great product, a solid team and solid offering in the markets they serve- each of them- but just needed some help behind the scenes which the Bravo money would have provided. The Merge play, by comparison, is ALL about money. If I was an AMICAS stockholder I would be pi$$ed that the decisions to accept the Merge offer was made without my input. This is especially disturbing since the initial stockholders meeting was supposed to be on March 4th and got pushed back till the 19th, yet the decision to accept the offer was made by the AMICAS Board of Directors on March 8th. Of course all the smart money in AMICAS got out while the getting was good and stock was in the high 5’s low 6’s so… he who hesitates is lost.

Merge is also starting out behind the eight ball financially. In addition to leveraging itself beyond belief. AMICAS paid Project Alta Holdings Corp., ("Parent") and Project Alta Merger Corp., an affiliate of Thoma Bravo, LLC, a termination fee of $8.6 million, half of which was reimbursed by Merge. So that’s $4.3M per company in debt right out of the chute. Add to that 12-18 months of significantly reduced revenue that is quite inevitable, the interest on the bridge loan that one sourced pegged at $6.5M per quarter, and other challenges of a similar ilk and you seem to have anything but a blueprint for success. But we can hope. And I do.

Will they both survive? I hope so. Am I an optimist? Hopes springs eternal here but he realist in me says otherwise…after all in more 25 years of being in this industry I have witnessed this scenario time and again haven’t seen differently..... but there is always the first time…

In February 2010, as a means of customer retention, GM announced it was offering existing Saturn owners up to US $2,000 in incentives on purchasing a new Chevrolet, Cadillac, Buick or GMC vehicle until March 31. Customers are required to have owned their Saturns for at least six months and are not required to trade them in to be eligible for the incentives. Maybe Merge should do the same- offer an incentive to stay with the companies products until we know what will ultimately happen…

So there it is- since you asked (or didn’t). Judy Collins wrote and sang the song “Since You’ve Asked” although I much prefer the version that Tim Weisberg and Dan Fogelberg did on their Twin Sons of Different Mothers album in years past. The lyrics are hauntingly familiar:

Take the roads that I have walked along,

Looking for tomorrow’s time,

Peace of mind.

That is all everyone wants…peace of mind…And if we don’t find it soon we may be singing the lyrics to yet another Collins tune- Send in the Clowns.

Don't you love farce?

My fault, I fear.

I thought that you'd want what I want...

Sorry, my dear!

Monday, March 08, 2010


Unlike Jimmy Buffett, she didn't step on a pop-top.  No, I don't know how it happened. 

Friday, March 05, 2010

Game Over

I got the call this morning from AMICAS, just before the press-release went out.  Game over, per the Board of Directors. Merge wins.  Here is the story from the financial news wires:

BOSTON and MILWAUKEE, March 5 /PRNewswire-FirstCall/ -- AMICAS, Inc. (Nasdaq:AMCS - News) and Merge Healthcare Incorporated (Nasdaq:MRGE - News) today announced that they will enter into a definitive merger agreement (the "Merge Acquisition Agreement") pursuant to which Merge will acquire all of the outstanding shares of AMICAS for $6.05 per share in cash, or an aggregate of $248 million. The Board of Directors of AMICAS has unanimously voted to terminate AMICAS' previously announced agreement with an affiliate of Thoma Bravo, LLC and to enter into the Merge Acquisition Agreement. Merge's $6.05 per share cash purchase price represents a premium of approximately 13% percent over the $5.35 per share price contemplated by the prior agreement.

Together, AMICAS and Merge will become a leading global healthcare IT provider, bringing together the best employees, customers and solutions in a broad array of image and information management and related solutions. The combined company's solution portfolio will range from comprehensive automation solutions for cardiology and radiology providers to enterprise content management solutions for IDN's to OEM solutions for health IT applications to trial, site and patient management solutions for pharmaceutical, biotechnology, medical device and contract research organizations.

The $6.05 per share cash purchase price represents a premium of approximately 38.8 percent over AMICAS' volume-weighted average share price during the 30 trading days ending December 24, 2009, the last trading day prior to the public announcement of AMICAS' merger agreement with Thoma Bravo, and a 55.8 percent premium over AMICAS' volume-weighted average share price during the 90 trading days ending December 24, 2009.

The companies expect to promptly execute a definitive Merge Acquisition Agreement for a two-step transaction. The first step will be a cash tender offer for all of AMICAS' outstanding common stock, and the tender offer is expected to commence in about two weeks. The second step will be a merger pursuant to which any untendered shares of AMICAS common stock will be converted into the right to receive the same $6.05 per share cash price. The tender offer and merger will be subject to certain closing conditions, including successful tender of a minimum number of shares of AMICAS common stock, antitrust clearance and other regulatory approvals, and is expected to close in the second quarter of 2010. There is no financing condition to the consummation of the transaction.

Stephen Kahane, MD, president, chief executive officer, and chairman of AMICAS, said, "Throughout this process, AMICAS' Board has been focused on maximizing stockholder value and our agreement with Merge Healthcare demonstrates that commitment. We are proud of what we have built at AMICAS, including the solutions we deliver, the intimate partnerships we have with our customers and the excellent reputation we have in the marketplace. This transaction with Merge validates the strength of the business we have built. We look forward to working with Merge to complete the transaction as expeditiously as possible."

"We are very pleased with this significant positive step toward successfully combining these two great companies," said Justin Dearborn, Merge CEO. "Merge and AMICAS have strong histories of innovation in medical imaging software, experienced employees and engaged customers. As a combined company, our suite of health IT solutions will encompass a broad range of medical and biopharmaceutical imaging solutions to meet the needs of today's medical imaging providers. In addition, Merge's OEM and CAD technologies, international and eCommerce distribution channels, and additional market segments such as clinical trials provide new opportunities for AMICAS products and customers. On behalf of everyone at Merge, I look forward to welcoming and working closely with the AMICAS team."

Merge has obtained $240 million of debt and equity commitments to finance the transaction. Merge and Morgan Stanley Senior Funding, Inc. have executed a definitive commitment letter for $200 million of debt financing. Merge also has $40 million of equity purchase commitments from private investors for the issuance of Merge common stock and a new class of Merge non-voting preferred stock.

Prior to entering into the Merge Acquisition Agreement, AMICAS will terminate its previous merger agreement. In accordance with that agreement, AMICAS will pay an affiliate of Thoma Bravo a termination fee of $8.6 million, half of which will be reimbursed by Merge.
Let's read between the lines.  Dr. Kahane and the Board had no choice.  The moment the Thoma Bravo offer was revealed, a dozen sharks law-firms announced "inquiries" into the propriety of the deal.  In other words, some investor thought Bravo's offer of $2 per share above the then-current stock price wasn't good enough.  Were they put up to this by Merge?  I haven't a clue.  Ultimately, Merge's offer was 13% higher per share, which amounts to a whopping $70/100 shares. 

I have to add the following movie reference to Mike Cannavo's a few posts below.  (Being a Star Trek fan, I have to relate everything to that more ideal universe).  The setting:  Sarek, Spock's father, thanks Captain Kirk for saving Spock, even though Kirk's son was killed and the Enterprise was destroyed in the process:
Sarek: "Kirk, I thank you. What you have done. .. "
Kirk: "What I've done, I had to do."
Sarek: "But at what cost? Your ship, your son."
Kirk: "If I hadn't tried, the cost would have been my soul."
Thoma Bravo's bid, in the end too low, came with the intent of preserving the "soul" of AMICAS.  How many AMICAS shareholders owned more than 1000 shares? Merge's price yields said shareholders $6,050, minus commission. Thoma Bravo would pay $5,350. $700 is apparently the price put on the soul of AMICAS, and the soul of the investors as well.  The bottom line is the bottom line, I guess.

Dr. Kahane's statement, "Throughout this process, AMICAS' Board has been focused on maximizing stockholder value and our agreement with Merge Healthcare demonstrates that commitment."  Partial translation, according to Dr. Dalai:  "The board would have been sued had we not taken this offer."  This is the world in which we live, folks.  Shakespeare had it right in King Henry VI (Act IV, Scene II):  "The first thing we do, let's kill all the lawyers".  (Friends and family members who are lawyers are of course excluded.)

If there's one thing one learns in medicine, it is to deal with reality.  The Merge purchase apparently will happen, and we will adjust accordingly.  I consider myself one of AMICAS' more loyal customers, and without question, I am its loudest customer.  With that in mind, I have a message for Merge's CEO, Mr. Dearborn:
First, congratulations on this acquisition.  Clearly, you and I both realize that AMICAS is an incredible company.  I have used AMICAS PACS software for many years, and I find it superior to anything else I've tried.  You have just mortgaged your company to the hilt to buy AMICAS, so I have to assume that you and Merge see the same level of value. 

But AMICAS is far more than a collection of software.  AMICAS is nothing less than the sum of its people.  I know them well,  I have worked with these people for years, and they are the finest in the business.  They LISTENED to me and radiologists like me and created a PACS that WORKS and doesn't get in my way.  Then they recreated it and improved it yet again, starting from scratch and doing it one better with Version 6. 

I favored Thoma Bravo's offer over Merge's because I was assured that the former would leave AMICAS alone, in the style of Warren Buffett and Berkshire Hathaway, to do what it does well.  You are about to spend $240 Million on this company.  I challenge you, Mr. Dearborn, I beg you, I implore you to do the same:  Keep the AMICAS team intact.  These people know what they are doing, and they do indeed do it well.  Let them continue to do so.  I'm depending on that, and so are my patients.  I have advised those in the PACS market to strongly consider purchasing the AMICAS product. 
I must put that recommendation on hold until I have your personal assurance, Mr. Dearborn, that the AMICAS product line will go on unscathed under Merge's control, that AMICAS customers will receive the same level of service that we have become accustomed to over the years, and that upgrades and new developments from AMICAS will continue as they would have before Merge came on the scene.  In essence, let the AMICAS team do what they have been doing so well for so long.  Don't fix what isn't broken. 
Please talk to us, your new customers, and learn just how important AMICAS, the company, its people, and its product, is to us.  And by the way, I would very, very strongly suggest that the new company be called. . . AMICAS. 
I'll let you know if Mr. Dearborn responds.  But I'm standing by my words above.  While AMICAS is still my favorite PACS, I must advise anyone considering a purchase to put it ON HOLD until we know where we stand.  Don't go buying something else just yet if you can possibly wait, but. . .

Wednesday, March 03, 2010

Uneventful Post Op Course

My son had surgery yesterday at the Really Big Hospital in the Really Big City hours from our smaller town in the South.  Thanks to God, and the skill of a very fine surgeon, my son is doing quite well.  We are now 30 hours out from the procedure, and he's been up walking around several times already.  His mom and I are thrilled and relieved, and hope and pray for a continued uneventful post op course. 

My son's procedure was neither elective nor emergent per se; it had to be done fairly soon, though not on an emergency basis.  The surgeon and the hospital worked with us to find the time that would impact his schooling the least, which was within a few weeks of the time we decided to go ahead with the operation.  I have nothing but praise for this hospitals' operation (pun intended), especially the first-rate nursing staff doing their thing efficiently and with obvious caring for their patients. 

The experience of course makes me wonder how something like this would go if our friends the Democrats achieve their goal of socialized medicine, and have no doubt, that is their goal.  I am fortunate enough to carry insurance that allows me to go beyond our area, "out of network" as they put it, to seek the best care for my family.  Some policies might have limited us to some extent, but not like one might see in Canada, for example.  Since this wasn't an absolute, life-threatening emergency, the procedure would most likely have been postponed for several months, even a year.  By that point, things could have deteriorated, he might have had to miss even more school, we might not have been able to go to the surgeon or the hospital we wanted.  In other words, our choices would have been made for us, by beaurocrats who neither knew us or cared about our situation.  Argue all you want, this is how I believe it would be, and deep down, you know I'm right (pun intended once more). 

While I am a staunch conservative, and I believe strongly in the free market, the current potential disaster with Merge attempting to swallow the larger AMICAS, points out that at least for health-care, the free-market is far from perfect itself.  Because of the need to please the stockholders, and to handsomely reward the C-suite, profits, and the bottom-line stock-price have become the end all to end all.  This pushes secondary issues, such not allowing company A to be demolished by company B (or G or M) in the course of playing a high-stakes game to bolster their languishing stock.  As a friend of mine put it, whatever happened to "Doing well by doing good?"  (He also suggested, tongue-in-cheek, that GE had put up the funds to back the loan to Merge just to annoy me.)

The same friend wrote this response to Mike Cannavo's piece posted below. 

My dear friend, Mike.

I've just read what may be your magnum opus on Dalai's blog site (thanks, Dalai!). Very well stated and I loved the movie references and quotes.

As I will probably soon pass into what will be early-retirement hell, I look back at the health care companies I've worked for and thoughtfully considered the messages they passed to their hard-working employees: "You do not matter. You are an insignificant cog in a wheel driven by faceless, emotionless investors. We do not care if your wife has cancer or you have heart disease. We will do whatever it takes to produce a profit and/or a return for the few executives who ran the risk for an early buy-out and pay-off. We will burn you out, lay you off and disrupt your family - whatever it takes."

I went into a care-driven health care career many decades ago, an idealistic and naïve hippie wannabee raised by working class parents in a mom & pop wholesale business. Doctors drove beat-up station wagons and charged $5 for office visits. Medicare didn't exist and there was no Humana, HCA, or Tenet. All health care was not-for-profit and driven by good Catholics, Jews, Protestant groups and the state/county. I thought we all worked in a system that didn't make the big bucks, but did good things for people who couldn't help themselves.

But, I fear that whatever may have been an altruistic desire to help others among health care workers is long gone. After my experiences in marketing for HMO, PPO, for-profit hospital, home health, computerized claims payment and imaging companies (which by the way, began out of financial necessity when the recession of the early 80's and prospective reimbursement ran me out of my allied health care career), I have seen the dark underbelly of the health care business. Witnessing the debacle with AMICAS and Merge has been the last straw for me.

I am disillusioned and resigned to sit by the shore and watch the sunset, munching on my ration of cat food and stale potato chips. I am happy that I will not be around in 20 years to see what has happened to our country, our health care system and to the welfare of my children, their children and the poor and elderly. God help us. Amen.
Sadly, the other side of the coin is just as distasteful.  Clearly, the quest for profit can hobble a company like AMICAS, lead physicians to order unnecessary tests, and drive lawyers to file a dozen unnecessary suits hoping to hit "the big one".  But the alternative is worse.  We all know the joke, "I'm from the government and I'm here to help you!"  It's a funny line because we know that help from the government is just not going to happen.  I could go down the list of huge federal programs that don't work well, and I would start with Medicare.  That's the best example, because the elderly (an age I'm fast approaching!) and physicians have become dependent on this particular government dole, and we will vote for anyone who wants to give us more via this pipeline, and boot out those who would dare tamper with the fountain of lucre.  The fact that Medicare is $31 TRILLION dollars in debt doesn't phase anyone as long as they get their share.  And this is about as benign as government gets.  This lesson should not be lost on those who would trade Wall Street greed for Washington's benevolent narcissism. Greed I can understand, but the drive to dominate others because "I know better what you need than you do" is beyond me. Our liberal friends would like to control 1/6 of the economy via an entitlement so massive we would all be completely be dependent upon them for our very well-being.  As I've been saying, if government controls your healthcare, it controls your life, and I believe that now more than ever.

The answer is for each sector to do its thing properly balanced with its counterpart.  When that equilibrium is disturbed, we get an out of control situation.  When the liberal Barney Frank and Christopher Dodd pushed through their liberal plan to force banks to give loans to those who couldn't possibly pay them back, the financial industry found the loophole of derivatives and other shams.  The market reacts in unexpected ways to abnormal pressures.  The US private sector delivers the best healthcare in the world, as evidenced by the fact that anyone who can travels here for high-level care.  When did you last hear about someone going to Canada, or Britain, or Japan, et. al. for care they couldn't get here?  Under total governmental control, this will not be the case, and even if the control is partial, there will be deficiencies, shortages, and all of the other problems manifested in all of the other systems we are supposed to envy.  This isn't the direction to go.  Rather, we need to restore the balance between private and public.  At least in healthcare, the government should regulate, not provide. And the private sector needs to be regulated.  Conservative though I am, I am not so naïve as to think that the market can totally police itself.  But I'm totally convinced that the government is incapable of doing a better job of it.

So, I'm hoping for an uneventful post op course for the US health care system.  It needs a bit of minor surgery, but let us hope that the surgery is far less extensive than Dr. Obama and his liberal partners would recommend.  I'm talking appendectomy vs. brain transplant.  And I'm hoping my son's post op course remains uneventful as well.


I've already received a couple of comments.  One was nothing more than a collection of liberal talking points which we've all heard a thousand times before.  Everything is Bush's fault, from Cain murdering Abel on down.  Read it at your convenience, if for nothing more than a glimpse into liberal thinking.  The second was a bit more brief and bears review.  In reference to the fact that I and my family are insured, Anonymous writes:
And what would the outcome have been if this were not the case? 
In the "every man for himself" world, you'd be out of luck, I guess?
Here we have the honest-to-gosh true-believer liberal incentive for socialized medicine.  (I contrast this with the Leftist political motivation, which is to create an enslaving entitlement to guarantee perpetual power.)  A lot of liberals out there cannot stand the fact that some get more than others, that some have more and some have less, and this discrepancy is especially galling in the realm of healthcare.  Everyone should have the same care, which of course must be provided by the government and funded by spreading the wealth around, i.e. the "rich" should pay for it.  

While I'll be the first to tell you that our system needs some surgery, I do not believe it needs to be completely gutted so as to provide Cadillac care to everyone.  That is not feasible, and to do so at government expense would bankrupt the nation within a year.  

What is never stated anywhere is that the poor, and the uninsured (and they are not necessarily the same group) DO get treatment, from the ER's and from physicians like ME who treat first and ask questions later.  I will not refuse a patient who cannot afford my services.  That is part of my duty as a physician as I see it.  I do not believe in the scenario of "every man for himself".  I believe there should be a safety net of some sort for those who HONESTLY need it, and right now I and physicians like me provide it.  This could certainly be done better, but we don't need to destroy the entire system and gouge "rich" people to do so.  Please tell me, however, why "rich people" pay to insure those who spend their wages on illegal drugs, cigarettes, payments on cars beyond what they need or can afford, iPhones with $100/month data service, bling of various flavors, and so on and so on and so on, instead of health care.  I could go on in this vein, but you get the idea.  Anonymous is upset that I earn a living and have a better insurance policy than someone who doesn't.  It's just not FAIR, and that is why liberals think the government should be distributing my "wealth" all around.  To me, that isn't FAIR, but of course, I'm biased.   

Let me tell you of an incident that occurred within the past 24 hours.  My son is recovering on the surgical floor of the Really Big Hospital in the Really Big City.  Last night, the patient down the hall had a bit of a problem, a creating a disturbance which I won't describe.  This happened again this morning at 6AM.  I promptly called the senior administrator on duty and requested (not so nicely) that the patient be moved.  I was met with a polite response mainly outlining the other patient's rights and needs, and not really acknowledging those of my son.  I elevated my physician-esque distemper to surgeon-level, and suggested that this needed taking care of NOW.  To make a long story short, the other patient was moved, and we were visited by most every administrator who might have something to do with patient-care issues.  We all said the right things, them apologizing profusely for the problem, and me praising the nursing care to the hilt (praise which was well-deserved, by the way).  But in the process of this political dance, one did admit to me that this Really Big (Private) Hospital was having to take on the characteristics of a downtown urban facility, with more and more problem patients coming through their doors every day.

If we were to achieve the Liberal ideal of perfect equality and universal care for all, can you imagine how different things might have gone?  My son might have been on an open ward with the patient in question, rather than in a private room.  There might not have been adequate personnel to deal with the situation.  And you can rest assured that in this totally egalitarian Liberal paradise, the complaints and fears of a parent, even a parent who happens to be a physician, would go unheeded, and would probably be fodder for amusement in the break-room (where the employees enjoy their mandated 15-minute break every half-hour).

Extreme?  An exaggeration?  Maybe.  The British and Australian systems, amongst others, do allow one to purchase extra-cost private care, so there is the option to get away from this terrible situation, much to the chagrin of those who want everyone to be treated EXACTLY the same.  But what about other places where Liberals have totally won the day and truly create a government-funded paradise of equality--equal squalor, but equality none the less?  This link shows you the worst of the public British system, and you cannot deny that this fine example of socialized medicine is anything but a screaming success.  My scenario might be far fetched, but in your hearts, you know I just might be right (same pun, one last time).