Varenye is a term I came across in Ari
Shavit’s book about the birth of modern Israel, My Promised Land. Varenye is a
jar of fruit preserves stored in the cupboard by Eastern European Jews. This
food is reserved for times of trouble (pogroms mostly). Varenye feeds your
family when there are no other sources of nutrition. Varenye is a back-up plan.
It came up in the book because Varenye
was Golda Meir’s name for the chief engineer of Israel’s nuclear facility in
Dimona in the Negev desert. Dimona doesn’t exist. Never has. But Dimona is what
has kept Israel alive throughout the past 50 or so years since it went live in
the 1960’s and began producing the stuff of nuclear weapons that has created a
massive imbalance of power in the Middle East in Israel’s favor.
Israel’s first leaders were rather
split on the notion of developing this destabilizing potential. Thank goodness
Ben Gurion won out and the Isarelis had the wherewithal to hold off those who
would destroy the nascent nation. Having Varenye in the cupboard is always a
President Obama has no Varenye in the
Middle East today. He has no fall back and no secret weapons. He has no good
will and no allies. Oh yes. He has one. The country with its own Varenye,
Israel. No matter how often the American President and the current Israeli
Prime Minister differ in their views on solutions in the region, they will
always have one thing in common—Israel’s Varenye should its enemies attempt to
create the existential crisis that every Jew knows is real since the Holocaust.
(I am really sorry if you do not believe this, but it is true. It is not
paranoia if they are really trying to kill you and all Jewish holidays are
celebrated similarly: They tried to kill us. We won. Let’s eat.)
American medicine needs a Varenye as
well. We don’t have one. We mistakenly believe that the needs of individual
patients for our healing skills will preserve our longevity. It will not. There
are doctors from all over the world willing to do what American-trained doctors
will do either by coming here to practice or having patients fly to them,
so-called medical tourism. Either way, the care will be delivered at a lower
price than is available in the US. We have been outflanked by the insurance
companies, big pharma and the large hospital systems who more than ever are
telling us how to practice. What’s worse, the very people who cannot develop a
Varenye for the Middle East (our government) have bested us with legislation
that does almost nothing and then tries to convince the country that it is
great (if they are Democrats) or evil (if they are Republicans). The fact of
the matter is that the ACA ain’t great and the insurance companies are evil.
Can we develop a medical Varenye to get
us through the persecution we are suffering? We can, but we have got to start
walking the walk and not just whining.
We are going to have to try to deliver
the best care we can and get used to being reimbursed less for it.
We need to insist on being paid for
thinking as well as doing. That means the proceduralists may have to forego
some dollars to the listeners.
We must develop a system of payment
that is far less complicated so that we can fire the million or so people it
takes to administer the current system and whose paychecks run up the cost of
We need to eliminate the tax advantage
of employer provided insurance.
We need to teach our kids to be better
patients than our generation was and is.
We need to incorporate a value
calculation into any new medicine or technology. Everyone cannot have
everything he or she wants simply because someone else is paying for it.
Mostly we need to return to being
advocates for our patients and not ourselves. Remember when you sacrificed
sleep to care for poor people during your training? How about sacrificing some
money and doing it again?
As I have said in this blog repeatedly,
there is nothing of which I am prouder to be a part than the fraternity (and
sorority) of physicians. But being a Jew is a close second and my favorite
group could use a little of the wisdom of my other group.
We need some Varenye in medicine
because between the insurers, the drug companies, the hospitals and the
government, it sure feels like a pogrom to me.
The difference between the Varenye of
modern Israel and the Varenye needed in American medicine is that Israel’s
Varenye is now being challenged by that of Iran and possibly other states that
are enemies of Israel. If they get their nuclear Varenye, then the most
unstable region of the world is that more highly unstable.
American physicians are in the same
position as the Iranians. We are behind those who would control us—the
government, the insurers, the drug companies and the hospitals, who have a
Varenye called the ACA that preserves their revenue streams. We are playing
catch up. And unlike the Israelis who have shown remarkable restraint in even
acknowledging the existence of their Varenye in their various relationships
throughout the region and the world, the insurers have had no trouble flexing
their muscles to disadvantage the docs.
The Israeli restraint will only go so
far. If threatened in an existential fashion by the radicalism coursing through
the Middle East, the Israeli restraint will be tested. The restraint of
American physicians is also being tested by the ACA, Medicare, Medicaid,
regulatory agencies and drug pricing by big pharma. These entities have shown
no restraint. Why should we?