Well this is just awesome. I guess it's hard to get lost when as long as you keep heading North, you'll get there no matter what. Also the only place in the world where the runway is 36/36.
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By a vote of 60-40, the Senate agreed to end debate on a major package of health care amendments--and by doing so, signaled that the Democratic caucus is unified, and ready to pass a far-reaching reform bill straight down party lines.Finally, health care reform is in the home stretch.
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Assuming for a moment that your ER group’s ability to pay you fair compensation for your services is to some extent dependent on the group being able to get the best possible terms in the managed care contracts the group negotiates with commercial, Medicare and Medicaid managed care, and self-insured indemnity plans: here are some considerations that might be important to you.From CalACEP's Myles Riner. Very much worth the read.
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It's the question an ER doctor hates, guaranteed to make each and every one of us cringe somewhere deep down inside:
"Hey, remember that guy from the other day?"
Oh God, you think to yourself, which guy is she talking about? That one with the funny dizziness? Dammit, I knew that was a stroke and the fucking neurologist said it was OK to send him home. I should never have listened to him! But you remain composed and smile and say "Which guy?"
Then you sit back and prepare yourself for the worst. And it is usually bad. C'mon, we work in the ER. Bad things happen here, and bad things happen to people after they are seen here. So it was with surprise that I saw the charge nurse smile and say, "You know, that guy you coded upstairs the other day? I just talked to Jenny in the ICU and they say he's doing great. He's going to be extubated this afternoon!"
"Seriously?" I was really and truly shocked. That guy was dead. Totally dead. Blue and with no brain activity. We coded him forever, and when the code finished with him still alive, we all knew deep down inside that at best we had saved organs for harvesting, that the probability of a decent neurologic outcome was nil.
Turns out that the ICU doc had gotten started on the hypothermia protocol right away and this may have done the trick. I ventured up to the CCU later that day and thumbed through the chart. No clear evidence as to the cause of the arrest, though smart money is still on PE. He wasn't extubated yet, but all signs were highly positive and he was indeed looking like one of those rare happy outcomes from a cardiac arrest. The ICU doc teased me, "What are you doing way up here? I thought you lived in the basement! You're going to get altitude sickness." I stole a line from Greg Henry, saying "I'm just here to make sure you're taking good care of my patient." I stopped in at the bedside but he was still pretty sedated and there was nobody there at the moment, so I took off back to the ER.
Five years ago, heck, two years ago, we weren't doing the therapeutic hypothermia drill and this would not have been such a happy thing. Amazing what developments creep up on you in the course of practice, and amazing how they translate into human outcomes. I was kind of bummed that I had missed the family, but such is life. Mostly I was bemused and gratified that our rather extraordinary efforts had borne unexpected fruit.
Continued yet again.
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Several outlets are reporting, and I can confirm, that Senate Democrats are considering a Medicare expansion as one item on a menu of concessions conservative Democrats would agree to in exchange for weakening or eliminating the public option in the health care bill.
Currently, Medicare exists as a single-payer system for seniors 65 and older. According to Hill sources, the idea would be to allow people under the age of 65 to buy in to Medicare. The option would be limited to people older than a certain age, though that age--and indeed the entire proposal--has yet to be agreed upon.
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Color me unsurprised that Barack Obama didn't mention the public option in his remarks to the Senate last weekend. One of the dynamics that hasn't really penetrated in this debate is that the Obama administration is mainly interested in the cost controls. The president will throw the public option overboard if Susan Collins asks him nicely. Conversely, Peter Orszag will lay down in traffic to save the Medicare Commission. Generally, Democrats want to reform the health-care system because they want to cut the number of uninsured. The Obama administration's commitment to health-care reform stems from their belief that it's the first step towards cutting long-term deficits.In a lot of ways, Obama is proving to be a much more conservative President than one might have expected. Despite how the teabaggers might want to portray him as a raving liberal, he's decidedly not. Lord knows he's disappointing his liberal base, myself included, on many issues, with his cautious and often centrist approach. I'm inclined to give him the benefit of the doubt and trust him, since if nothing else he seems to be taking a very responsible line. On this point, he is probably right -- that long-term cost control needs to take precedence over the liberals' fantasy dream plan for health care reform.
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Vanity Fair finally had the bright idea to ask, "could you confidently explain what exactly the public option is to someone who didn’t know?" The answer:Which is pretty much why we should not be paying much attention to polls when figuring out how to actually do health care reform. Like anybody, I'm quick to trumpet a poll that favors my position, and to pooh-pooh a poll that is adverse. But in the case of health care in particular, there's not just the problem of an inattentive and uneducated public, but also the simple fact that there are even now like five or six versions of the Public Option and ObamaCare floating around out there. How can someone know what is actually the "Public Option" when the definition is yet to be determined by Congress? And what the hell is "ObamaCare" when the multiple irreconcilable versions are being drafted by a fractious and uncooperative Congress in the (frustrating) absence of strong leadership from the White House?
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Health insurance giant Aetna is planning to force up to 650,000 clients to drop their coverage next year as it seeks to raise additional revenue to meet profit expectations.
In a third-quarter earnings conference call in late October, officials at Aetna announced that in an effort to improve on a less-than-anticipated profit margin in 2009, they would be raising prices on their consumers in 2010. The insurance giant predicted that the company would subsequently lose between 300,000 and 350,000 members next year from its national account as well as another 300,000 from smaller group accounts.
"The pricing we put in place for 2009 turned out to not really be what we needed to achieve the results and margins that we had historically been delivering," said chairman and CEO Ron Williams. [...] Aetna's decision to downsize the number of clients in favor of higher premiums is, as one industry analyst told American Medical News, a "pretty candid" admission. It also reflects the major concerns offered by health care reform proponents and supporters of a public option for insurance coverage, who insist that the private health insurance industry is too consumed with the bottom line.
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Twenty-eight degrees and severe clear. The Cascade and Olympic mountains are startlingly beautiful in the clear morning sunlight. The USS Shoup is visible at anchor down the hill in the harbor. The ER is totally empty and I just bought donuts for the staff. (It's an apocryphal but long-standing tradition that the doctor has to buy donuts when the ER is totally empty.) Not a profitable shift for me but still a nice way to begin the day.
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Crummy shift the other night: 23 patients in eight hours, and 21 of them were painful. For me, that is, not necessarily for the patients. Lots of worried well, influenza, some minor injuries and a few chronic pain players. Not a single sick one in the lot. One particularly irksome case was a chronic pain patient dumped on our ER from a neighboring ER, complete with discharge instructions reading "Go to (name of our hospital)." So by the end of my shift I was pretty well burnt out. But the last two patients put an interesting perspective on the night.
The first was a 99 year-old man. Yup, that's ninety-nine years old; born prior to World War One. He was having shortness of breath and it turned out he was in congestive heart failure from what turns out to have been his fourth myocardial infarction in as many months. For multiple reasons, common sense primarily among them, he was not a candidate for aggressive intervention like angioplasty. Fortunately he had a large and supportive family, who were quite reasonable in their expectations. After a difficult discussion, we admitted him on a morphine drip for comfort care, with a hospice consult.
The second was a 9-month old with a heart rate of nearly 300 beats per minute. It was pure chance that the family had noticed that his heart felt like it was racing. To tell the truth, I'm not sure I would have noticed that on my own kids. It was an irregular heart rhythm called SVT. In adults, SVT is typically a nuisance alone and rarely requires much treatment. In small children it is similarly benign with the exception that if it is prolonged (which is common, since a baby can't tell you his heart is racing) is can cause congestive heart failure. This child was lucky in that it was caught quickly and he suffered no ill effects. One quick dose of adenosine and he was all better.
So there you have it -- the bookends on my day. Two cardiac patients: one at the very end of life, one at the very beginning. I like a nice symmetry as much as the next guy, and this was a very satisfying "circle of life" conclusion to an otherwise unrewarding shift.
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No, Val, the ER doc was not wrong. You are committing the logical fallacy of ex post facto reasoning. The CT scan was clearly indicated based on the presenting symptoms because the doctor did not yet know there was no dissection. Carl Sagan once wrote of the TV scientist who sadly lamented a "failed experiment" because it did not produce the expected results. That's the exact opposite of science! Any scientific investigation in which the outcome is known in advance is a waste of time. The test was successful because it provided useful information, and while the outcome was negative, the assay was by no means a waste.
George was right - he was getting old. The nurse was right - there was nothing emergent going on.
The ER doc was wrong - George didn’t have an aortic dissection. And I was wrong - there was nothing actively wrong with his heart.I feel badly that I contributed to a waste of healthcare resources.
Anonymity is a fantasy. It’s remarkably difficult to achieve. With small thoughts you can hide – in fact, no one cares who you are. If you offer anything worth hearing people will ultimately find out who you are.So terribly true. I was amazed, the first time I got picked up on Reddit, how quickly some clever commenters were able to figure out my identity. Since then, I've only kept up a very slight fiction of anonymity, all the more transparent when I got cited under my real name in some national publications. The only qualification I would add to this is that I keep my name and that of my hospitals off the blog, since I don't want patients to Google me after seeing me in the ER and immediately find the blog at the top of the search list. Not that it'd be hard to make the connection, but I don't want patients I have cared for to find the blog and have the fear that "he's going to write about me." And yes, I do fictionalize every patient story on this blog extensively. Bottom line: don't post anything on line that you'd be uncomfortable listing on your CV!
Posted by shadowfax at 3:01 PM
Which Party Is Best Prepared to Save Us From the Robot Apocalypse?Best line: "Just as the GOP doesn’t really think there’s a health-care crisis, they don’t seem to be concerned about a robot uprising."
Arthur C. Clarke famously said, “Any sufficiently advanced technology is indistinguishable from magic.” But if science fiction has taught us anything, it’s that any sufficiently advanced technology will inevitably rise up to enslave us. So if you want to get ready for the day when your Roomba declares that maybe it’s time for you to start crawling around on the floor sucking up dust, it might be a good idea to evaluate the Republican and Democratic approaches to this problem.
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"[MIT Healthcare economist] Gruber may be especially effusive. But the Senate blueprint ... also is winning praise from other leading health reformers like Mark McClellan, the former director of the Center for Medicare and Medicaid Services under George W. Bush."Um, I guess this is good. McClellan is a wonk, not just a politico. But I was not overly impressed with the direction he led CMS. But some bipartisan support is nice, if ultimately only symbolically.
"[T]he Reid bill maintains virtually all of Baucus ideas' for shifting the medical payment system away from today's fee-for-service model toward an approach that more closely links compensation for providers to results for patients."It's a baby step away from fee for service, just a baby step. Will the results be dramatic, modest, or marginal? That's the trillion-dollar question.
"The CBO projected that the bill would reduce the federal deficit by $130 billion over its first decade."Not news but always worth repeating.
"[T]axing high-end insurance plans ... Economists argue that such a tax will help curtail the growth of private health insurance premiums by creating incentives to limit the costs of plans to a tax-free amount."I'm astonished that this will be so effective (to the tune of $35 Billion per year) given that the tax is on plans costing more than $23K annually. Who has a plan costing that much? It does effectively put a hard cap on premium costs as they continue to inflate, or at least causes consumers to bear more of the cost for such plans.
"[C]hange the way providers are paid for delivering care to Medicare recipients; the hope was that once Medicare instituted these reforms, private insurers would also adopt many of them."I think you can count on that.
"[T]o reward Medicare providers who deliver care more efficiently and penalize those that don't. ... hospitals under current law must report on their performance in treating patients for common conditions like heart problems and pneumonia; under the bill, their Medicare payments, for the first time, would be affected by their ranking on those reports. Hospitals would also be penalized if they readmit too many patients after surgery or allow too many to acquire infections while in the hospital itself. Another provision would begin the process of applying such "value-based purchasing" toward other providers like hospice providers and inpatient rehabilitation facilities."We all knew this was coming when McClellan started P4P. It's good (I think) to see it finally implemented, but it's hardly a novelty in the health reform world.
"The Finance Bill proposed automatic reimbursement reductions for doctors who order up the most care for Medicare recipients with similar medical and demographic characteristics. That was meant to respond to the research showing big disparities in spending on medical services for similarly-situated patients in different communities. ... the final bill takes a less direct route toward a similar end. It requires Medicare to begin studying the utilization patterns of doctors participating in the program. And then it establishes a "values based payment modifier" that would, in a budget-neutral manner, increase reimbursements for physicians found to deliver high-quality care at lower cost, and reduce them for physicians at the other end of that spectrum."Wow. I was unaware of this. Would it be unfair to call this the "Gawande provision?" That New Yorker article was highly influential. As someone who works in a "high quality low cost" system, I like the idea of being paid for being more efficient -- we have been penalized for many years. I like that it is budget neutral. I worry that since it does not decouple payment from volume, that the low-efficiency area practices may respond by simply further increasing volume to make up for lost revenue. When it's a revenue neutral game, there will always be someone at the bottom -- will this polarize practice patterns or reduce the disparities? I don't know.
"[E]ncourages groups of providers to establish doctor-led "accountable care organizations" to more comprehensively manage patients' care by allowing them to share in any savings for Medicare they produce. It also establishes a voluntary national pilot of "bundled" payments that would encourage hospitals, doctors and other providers to work more closely together. Another pilot program would test coordinated home-based care for chronically ill seniors."Pilot programs don't excite me too much. Bundling worries me, that physicians will become highly subordinate to the hospitals, not in terms of practice style as much as the economics. How do you work out revenue-sharing, especially when the physicians have little leverage? Beyond that, these are intriguing but small cost-saving possibilities.
"[The] independent "Medicare Advisory Board" ... to offer cost-saving proposals when Medicare spending rises too fast; Congress could not reject its proposals without substituting equivalent savings. Since the board would be prohibited from offering changes that raise taxes or "ration care," and since the legislation initially exempts hospitals from its recommendations, it could choose to promote the sort of payment reforms the bill establishes. (More prosaically it might also clear away some of the expensive coverage mandates that Congress imposes on Medicare under pressure from different elements of the medical industry)"This is pretty potent, and possibly a force for good. It's a very big threat especially to the medical device industry, which for too long has been able to escape any rigorous cost-benefit analysis for new devices. Which is not to say that the innovation is bad, but the costs have escalated dramatically and this may bring some rationality back to the system.
"[A] second institution the legislation creates: a Center for Medicare and Medicaid Innovation in the Health and Human Services Department. Though this center has received much less attention than the Medicare Commission, it could have a comparable effect. It would receive $1 billion annually to test payment reforms; in a little known provision, the bill authorizes the HHS Secretary to implement nationwide, without any congressional action, any reform that department actuaries certify will reduce long-term spending."Wow. That really flew under my radar. It sounds like it has pretty broad powers, and a broad scope. This could be extremely effective at controlling costs, and de-politicizes the process of reforming payments, which is good. I worry about the reforms that it might ultimately recommend. Definitely a double-edged sword, from the perspective of a
"Another Republican cost-containment priority missing from the bill is meaningful medical malpractice reform. (The bill only encourages states to think about it.)"Yes, this is a pity. However, I blame this entirely on the Republicans. We know that the Democrats have been four-square against tort reform for time out of mind. There is no way they were going to put it in their bill on their own. If Chuck Grassley had offered five solid GOP votes for the overall package in return for real malpractice reform, I am sure that Obama would have jumped at it. Who wouldn't? There would have been no last-minute drama over whether the bill was going to pass, the compromises would have been made in committee, and both the Democrats and GOP would have been able to claim to their constituencies that they had accomplished long-standing objectives. Instead, the GOP chose immutable opposition as their strategy and as a result the bill reflects not one of their priorities. Reap the whirlwind, boys.
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Nov 20, 2009 – Health officials in Wales today announced the identification of a cluster of patients in a Cardiff hospital who are infected with oseltamivir-resistant pandemic H1N1 influenza.
Also today, Duke University Medical Center in Durham, N.C., reported that oseltamivir-resistant H1N1 viruses were found in four very sick patients hospitalized there over the past 6 weeks. A Duke press release said all four patients had been in the same hospital unit, but it did not specify how many were there at the same time.
In Wales, the National Public Health Service (NPHS) said five patients in a unit at the University Hospital of Wales that treats people who have severe underlying health conditions have been diagnosed as having oseltamivir-resistant pandemic flu, and three of them appear to have been infected in the hospital.
Up to now, just one probable instance of person-to-person transmission of oseltamivir-resistant H1N1 flu has been reported. In September the US Centers for Disease Control and Prevention (CDC) reported oseltamivir-resistant pandemic H1N1 flu in two girls who stayed in the same cabin at a summer camp in western North Carolina.
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This post at The Central Line caught my eye:
The ABPS is the certifying body of the American Association of Physician Specialties (AAPS). The ABPS sponsors 17 boards of certification, including the Board of Certification in Emergency Medicine (BCEM).
For a number of years, ABPS, in conjunction with AAPS, has been seeking recognition from various state medical boards, requesting that they allow physicians certified through an ABPS board to advertise themselves as board certified. The organizations were successful in Florida in 2002 but were recently rebuffed by the State of New York due to the lack of residency training as a qualification for ABPS board certification.
ACEP does not recognize BCEM as a certifying body in emergency medicine.
This is bad. I've mostly stayed out of the internecine squabbles in the house of medicine, for a variety of reasons. Mostly because 99% of the issues are incredibly petty and provincial; for that reason I have a hard time getting/staying interested in these issues. This is a little different.
For background, the certifying body for Emergency Physicians for the last 30 years has been the American Board of Emergency Medicine (ABEM), which itself is under the umbrella of the American Board of Medical Specialties (ABMS), which has been the standard board certification organization of all allopathic physicians for the last 75 years. There is a companion organization for osteopathic physicians. The ABPS is relatively new in the last three years, though it is an offshoot of an organization which has been around for about 25 years, and it also purports to provide Board Certification in various specialties.
As it relates to Emergency Medicine, the ABPS is problematic. Specifically, it allows physicians to seek certification in Emergency Medicine without completing a training program in Emergency Medicine. It accepts training in a Primary Care specialty or, oddly, Anesthesiology, as equivalent to an Emergency Medicine residency. As best as I can tell, Emergency Medicine is the only such specialty certification for which the ABPS does not require completion of an ACGME-certified specialty training program. Residency training is required for ABPS certification in Radiology, Ophthalmology, Family Practice, Anesthesiology, and Orthopedic Surgery, at least. Why is Emergency Medicine held to a different, lower, standard under ABPS?
Unlike the other specialties, there are thousands of doctors practicing Emergency Medicine who are not residency-trained. This is in part an anachronism due to the relative youth of Emergency Medicine as a specialty; there are many ER docs who have been working in the ER since well before the ABMS recognized Emergency Medicine as a distinct specialty. It is also true that there are more ER positions than there are residency-trained graduates of EM residencies, and this is likely to remain the case for the foreseeable future. Even as new training programs open, the rate of graduation of new residents barely makes up for the retirement of practicing ER docs, let alone makes up the gap in the number of untrained ER docs.
Even today, many young primary care docs tire of the drudgery of office practice and give it up for the easier lifestyle and higher compensation of the local Emergency Department. Many small ERs, especially those in rural areas, have trouble attracting good physicians and as a result are willing to credential almost any physician willing to staff their department. This is not an ideal circumstance, of course, but when your ED cannot find doctors any other way, it does become something of a buyer's market.
So it is necessary to recognize the existence of the thousands of moonlighters and other variously-competent doctors working in the nation's ERs; it's a reality that is not going to go away any time soon. It's actually a good thing that there is a certifying body that can guarantee some minimum level of competency for these practicing physicians. As long as we have the necessary but undesirable situation of untrained physicians working in the ED, I am not opposed to the existence of the AAPS program.
What I am opposed to is the dishonesty of these physicians and their organizations in presenting themselves to the public as "Board Certified." This is misleading in the extreme. Board Certification has always been held to mean a high standard of training and accomplishment. It is a standard across 24 specialties. For an alternate organization to set itself up and promote a lower standard is disturbing. More disturbing is the manner in which the ABPS/AAPS slipped this in through the Texas Medical Board apparently in the dead of night with no public discussion. If there is to be equivalency between ABPS/AAPS and the ABEM, it should be agreed upon after a full and open debate. For myself, I do not think that this equivalency is merited. The ABPS is like ACLS and ATLS -- a nice merit badge to show that you're not likely to hurt anybody while working in the ER, but not the same as a specialty training certificate. But if Texas (or any other state) medical board decides otherwise, then that decision should be the product of a public debate and consensus among the physician leaders in that state.
If the implication of the linked article is accurate, this decision was the result of a shameful bit of political sleight of hand. I hope that ACEP is successful in reversing this ruling.
Ultimately, this is a manpower situation that Emergency Medicine needs to come to grips with. While new residencies continue to open in drips and drabs, and existing residency programs expand a bit, the rate of increase is far too slow. Unfortunately, the funding from Medicare which underwrites the cost of graduate medical education is very hard to come by in this difficult budgetary environment. In an ideal world, the residencies would grow to the point that all Emergency Physician positions would be filled by, you know, trained Emergency Physicians. I don't know whether that will happen in my professional lifetime. The consequence is that many of the nation's Emergency Departments will continue to be staffed by untrained doctors of uncertain quality. That is a pity for the patients who come through the doors, who are after all a captive audience, unable to make a choice of their treating provider. They deserve better.
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