Late night

I liked John Cale's version better, but a song like this is hard to do badly.

Award Fatigue

Thomson Reuters Announces 100 Top Hospitals Award Winners | Thomson Healthcare

The Thomson Reuters 100 Top Hospitals®: National Benchmarks study is based on the 100 Top Hospitals National Balanced Scorecard that evaluates performance in nine areas: mortality, medical complications, patient safety, average length of stay, expenses, profitability, cash-to-debt ratio, patient satisfaction, and adherence to clinical standards of care.

Our facility is on the list for, I think, the fifth year running -- this year we were the only hospital in our state so recognized.   It's natural after a while to stop paying attention to this sort of thing, but it really is a big deal.    It's not the end-all and be-all of hospital quality, but it shows that our leadership, our processes, and our caregivers are doing great work.   (I will take personal credit, of course.)  

Seriously, I am very proud of our institution.   From the OR to the ICU to the ER, we've accomplished some incredible things, and in an environment where financial resources are scarce.   To the (very) limited degree that I had anything to do with it, I'm pleased.  Mostly, I'm lucky to be affiliated with such a highly functional group of people.

Nice Gig

Got a nice email from pediatrician Rahul Parikh, med-blogger/columnist at Salon.   I wasn't even aware that Salon had a blog section.   Rahul also had a nice perspective piece at the LA Times yesterday.

I've not had time to peruse his work in depth, but he takes on the woo of Jenny McCarthy and the Mercury Militia, gives props to Obama's health care reform efforts, and covers the JAMA Mafioso response to their covered-up conflicts of interest.   So I like his perspectives and sense a kindred spirit.

More, I'm impressed by anybody that's able to write "real" columns, as compared to blog posts.   I've neither the time nor attention span to develop a thesis, research it, and pad it out to a thousand words, and then polish it to the point that it's fit for a major publication.  I throw out whatever occurs to me on a given day, anything that catches my interest, and if it's a bit half-assed or rough around the edges, I can live with that.  There's always tomorrow, or this afternoon, or whenever the next post goes up.   Not that I don't try to be thoughtful or have a point, but it takes a lot more craftsmanship to meet the standards of the LA Times.

So well done, Rahul.  I'll be keeping an eye on you, and don't be a stranger.

That's Just Bizarre

A 88 year old male with a history of steroid-dependent COPD and steroid-induced diabetes sustained a small cut on the palm of his left hand.   This was a 1cm puncture wound inflicted with a kitchen knife while washing dishes.   It was a minor cut, the bleeding controlled easily (despite the fact that he was on warfarin) and he did not seek medical attention immediately.  Three days later, he presented to his primary care doctor because his wrist and arm were swelling up; he was sent to the ER for assessment.

On exam, the patient had subcutaneous emphysema on the dorsum of the hand and circumferentially all the way from the wrist to the shoulder.   There was no erythema, tenderness, or fluctuance.   The wound was clean and dry without evidence of infection.  There was no pain with range of motion at any joint, and the compartments were soft (indeed, squishy).   The patient was afebrile and well-appearing, and the white count was normal.  An MRI of the extremity was obtained:

Uploaded with plasq's Skitch!

Uploaded with plasq's Skitch!

Uploaded with plasq's Skitch!

I apologize for the poor resolution -- for some reason I could not download the nice high-res images.   The black spots under the skin, between muscle groups, and (weirdly) around the bones is air.  According to the radiologist, there was no evidence of fasciitis, or any other inflammatory/infectious process.

A general surgeon, a hand surgeon, and an internist spent a while puzzling over this with me.   The big concern was that gas in the soft tissues is the hallmark of certain very bad infections -- think gangrene and the so-called flesh-eating bacteria, which are terribly life-threatening.   The patient didn't look infected, but being diabetic and on steroids and nearly 90, they sometimes don't show you the evidence of infection.   The MRI was more definitive that it was probably not infected, but if not, then how the hell did all that air get up there?

Ultimately, we played safe, admitted him for IV antibiotics and observation.   My theory was that the cut on the palm was acting as a sort of ball-valve mechanism where each time he opened and closed his hand, he pumped a little more air into the palm, which then tracked up the arm as more and more air got insufflated.  

People are weird.

The Uninsured

Long-time readers of this blog know that the crisis of the uninsured is probably the issue I care more about than any in medicine.  I care so much because I hate seeing these poor folks come into the ER with the consequences of their inability to find a doctor, and because I don't like not getting paid for what I do, and because the system that allows working people to fall into the gap between insurance and medicaid is so staggeringly unfair.

Doc Rob has a thoughtful and moving piece over at his place, from the office doc's perspective:

The Uninsured | Musings of a Distractible Mind

This is when one of my billing staff comes to me with the “what do you want to do?” question regarding them. Most of these are people I know. I don’t think of them as customers, I think of their kids and parents. I think about the medical struggles they have faced or the tragedies they have endured. I like my patients. Playing “hardball” is not that easy when you have an emotional attachment to your “customer.”

I don't have that problem, fortunately.   Unlike Rob, I am a commodity, and I am OK with that, and my interactions with patients are mostly one-shot affairs.  

But it puts a much more human face on "the uninsured," instead of viewing them as a nebulous mass of the great unwashed.

University of Chicago in more trouble

WhiteCoat has a reasonable rundown on the events surrounding last month's death in the waiting room at University of Chicago Medical Center -- as well as a satisfying but spurious idea of how UCMC should respond.   The news is that now CMS is looking into this as an EMTALA violation, which, based on the facts as presented, it almost certainly is.   The headline is that Medicare could pull its certification of the hospital, which is technically accurate, but terribly unlikely.

UCMC is in trouble.   There's no mistaking that fact.   They're being crucified in the media over their ER, and with good cause -- their ER is a nightmare, even for an inner-city academic center.   It seems to be a self-inflicted problem caused primarily by bad senior management -- not of the ER, but of the facility.

I've spoken and corresponded with some people with direct knowledge of the situation there.  The problem is that the hospital does not want to provide basic medical care as its sore mission.  They want to focus on their "Programs of distinction," and to the degree that general medical care is an impediment to that mission, they are willing to throw it under the bus.

The administration of UCMC portrays this as a financial necessity, which is half true.   Their motivations are clearly in part economic -- oncologic and surgical subspecialty services lines are far more profitable than general inpatient medicine, apart from the more favorable payer mix such referrals tend to bring.   However, to claim this is a necessity is an absolute sham -- UCMC has had operating income of >$80 million annually for the past two years running, with a better than 8% margin.  This is a staggering feat in the world of hospital finance.  Even in these difficult times, they managed to retain a 1.8% margin in the fourth quarter of 2008.

How to they do this?   Put simply, they ration care provided to the local community.   Although the medical center has over 590 beds, only 50 beds are available to medical patients admitted through the ER, and only 9 ICU beds are available to ER patients.   This in a facility with over 80,000 ER visits annually!   When a patient presents to UCMC's ER needing admission, if there are no "ED beds" available in-house, or if there are but the ER resident cannot convince the medicine resident that the patient "needs the university," then the patient cannot be admitted to the hospital, and must be transferred.   The ER residents spend more time making phone calls with neighboring facilities trying to arrange tranfers than they do providing direct patient care.

I can see some people saying, "Fine, I can see the logic in that, where's the problem?"  There might not be one if there was a receiving hospital right across the street that would take all transfers, no questions asked.   But that's not the case, and patients needing admission languish in the ER for many hours (and days) while the ER staff seeks an inpatient facility that will take them.   This reduces the number of beds in the department that are avilable for assessment and care of new patients.   The UCMC ED is already undersized, at 30 beds for 80,000 patients (generally, one bed is good for 1,500 annual visits, and at 2,000 visits per bed, an ER is considered over capacity), and if there are seven beds taken out of service, then the capability to move new patients through the department is hamstrung, as the department capacity is reduced by 25%.

The result?   Seven-hour waits to be seen, a LWOBS rate of 10-20%, and people dying in the waiting room.

And it gets worse.   UCMC recently closed its fast track and laid off its mid-level providers who had staffed it, many of them fifteen-year veterans of the facility.    If, as has been claimed, the crisis at UCMC was caused by a deluge of patients with minor conditions, then it makes no sense to close fast tract, but to expand it to streamline the flow of minor patients without consuming ED resources.   Unless, that is, your strategic goal is to eliminate the ED as a service line, in which case the next logical step would be to downsize the ER by a third, and reduce the inpatient beds available to ED patients by half.   Which is exacly what they planned.   After 190 of their doctors (mostly housestaff, it seems) signed a letter of protest, the university may have partially backed off of this plan.

But the message is clear: the University is actively trying to get out of their obligation to provide emergency services and is trying to position itself as a purely referral-based provider of specialty care.   They would probably close the ER entirely if the Illinois Department of Health would allow them -- which might almost be better than the tragicomic sham of an ER they are currently supporting (or, more accurately, failing to support).   In this, I don't blame the doctors and nurses staffing the ER at UCMC.   I've been at institutions where the administration did not support the ER, and there's no way to turn that around until there's a change of management.  I'm sure the clinical staff are doing the very best they can in the shameful situation their hospital has placed them.

There are a lot of factors nationally which place the emergency care safety net in jepaordy; this is not a case of the national picture on the small scale.   This is a case of a crisis caused by willful and deliberate mismanagement.

So with the firestorm of negative PR, condemnation by medical specialty societies, and now a death in the waiting room, is it finally time for UCMC to pay the piper?   It's encouraging that the trifecta of CMS, IL DOH, and TJC are displaying interest.   Whether real reforms come out of this will depend on exactly how aggressive the regulators' approach is.   I've been a victim subject of these agencies' tender mercies in the past, and they commonly take a very adversarial position in these matters.   Given the egregious nature of the policies UCMC has put forth, I have some cautious optimism that the regulators will hold their feet to the fire and demand real changes.  

Counter-intuitive

The complaint raised by conservative senators against the public plan option in a health care reform plan is that it would be an "unfair playing field" which would disadvantage private insurers.

My response has generally been dismissive to this line of argument.  The senators making it have generally been shills for the insurance industry and inclined to oppose reform in any case, so it's not overly cynical to view their objections as not entirely in good faith.  Even so, my thought has been, what of it?   Let the market decide.   If, as the conservatives fear, the public plan winds up being cheaper and better and the public freely votes with their feet and their dollars to choose it, then GREAT!   But if, as some doomsayers predict, the private insurers will select out the healthiest patients and the public plan winds up saddled with the sickest patients and highest costs, then isn't that good for the insurance industry?

Joe Paduda makes an interesting argument that the public plan would actually not be anti-competitive:

Sure, price is a factor - but it is not the most significant factor - not by a long shot. By keeping patients out of the hospital, a private plan would eliminate utilization and prevent price from ever becoming a factor. So, even if a service area was dominated by a public plan, a private plan that did a really good job of keeping members healthy and out of the hospital would deliver lower costs.

And also:

The reality today is that almost every market is already dominated by a very few health plans, so much so that in most markets, there really is very little market competition amongst health plans. [...]  If anything, a robust public plan would add competition to many markets, competition that would, if anything, increase consumer and provider choice.

How exactly is that bad?

Interesting perspective.   I doubt it will convince the AHIP advocates, but hopefully there's someone on the Hill explaining this sort of thing to Olympia Snowe and Arlen Specter.

End it, don't mend it

Doctors Call For Rebasing Medicare's Sustainable Growth Rate (SGR) - Health Blog - WSJ

Every year or so, we hear that some big Medicare pay cuts for doctors are on the way. Almost every time, Congress swoops in at the last minute to block the cuts. Leaders of the AMA and other big doctor groups have been in Congress lately asking for a change to the underlying system that keeps creating these near misses.

At issue is the “Sustainable Growth Rate,” a formula Congress created in 1997 to try to keep payments from spiraling out of control.

[...] Testifying at a recent Congressional hearing, leaders from the AMA, the American College of Physicians and the American College of Surgeons praised the budget. The AMA official called for setting a new, higher baseline for SGR.

I've also written about the SGR in the past.   Put simply, it was an index placed on physician compensation under medicare, enacted (IIRC) as part of the Deficit Reduction Act of 1997, designed to prevent medicare's physician costs from exceeding a certain fraction of the GDP.

Makes sense, when you think about it in the abstract, doesn't it?   But it never worked.  The number of beneficiaries grew, and they lived longer with more chronic illnesses, new technologies and services were developed, and GDP growth slowed, so the formula was triggered, and in 2002, physician compensation was cut by 2%.   Then in every subsequent year, the formula called for larger and larger cuts.   Three years ago, the cuts mandated were 10%; this year, the cuts mandated under the SGR total 21%!   But every year the Congress steps in at the last minute (and sometimes later) to stop the cuts.   Changing the physician compensation formula is such a daunting and politically exposive task, that they never take it on: just kick the can down the road to next year.

I've always thought that doctors were unfairly singled out with the SGR to begin with.  Why is it that there was a cap placed on the growth in expenditures for physicians, but not hospital expenses, nor medical devices, nor pharmaceuticals?   The real answer is because the AMA is a laughably impotent lobby. There's no rational basis for capping the growth of one expense -- the smallest -- and not the others, other than political strong-arming and opportunism.

Which is why I'm annoyed to see our leaders on Capitol Hill calling for setting a new, higher baseline for the SGR.   It was a bad idea, unfairly applied, and did not work.   To the degree that physician compensation is addressed in healthcare reform, the position of the physicians' lobby ought to be that the SGR should be ditched and not replaced.  Cost containment should not be applied to just one sector of the health care industry, and certainly not in such a blunt, indiscriminate manner.

Deep Thought

To the 22 year old young lady (gravida 9, para 4) I saw recently for issues related to her current, unplanned, pregnancy:

You, and your family, would probably be well served if you looked into the idea of birth control.

Just a suggestion.

Making me Laugh

Kung Fu Monkey:

There are two novels that can change a bookish fourteen-year old's life: The Lord of the Rings and Atlas Shrugged. One is a childish fantasy that often engenders a lifelong obsession with its unbelievable heroes, leading to an emotionally stunted, socially crippled adulthood, unable to deal with the real world. The other, of course, involves orcs.

Cost per unit delivered

CNN has an interesting anecdote about medial tourism:  a woman traveling to India for (I assume) a heart valve replacement, for about 5% the estimated price of the same procedure performed in the US -- travel included!

"They [U.S. hospitals] told me it would be about $175,000, and there was just no way could I come up with that," Giustina said. So, with a little digging online, she found several high quality
hospitals vying for her business, at a fraction of the U.S. cost. Within a month, she was on a plane from her home in Las Vegas, Nevada, to New Delhi, India. Surgeons at Max Hospital fixed her heart for "under $10,000 total."

Granted, the quoted price is the inflated price given to the uninsured -- the typical actual cost (or at least the reimbursement) for an open-heart procedure is, I think, closer to $40,000.   I am also assuming that this is an open heart, though the lede confusingly refers to the procedure as fixing "atrial fibrillation."  I can't think of any A-fib treatment costing $175K, but leaky valves can lead to A-fib as a consequence, so that's my guess.

On a related note, Ezra has a disturbing anecdote of an involuntary medical tourist:

Last weekend, my best friend, an aid worker in Sierra Leone, was in a motorcycle crash. Injuries were serious but not life threatening. The worst of it were three breaks in his leg: Two clean, one less so. After a couple days in a Sierra Leone emergency room, his evacuation insurance kicked in and he was flown to a small town in Germany (no one quite knows why) to receive treatment. My friend does not speak German. He does not know anyone in Germany. He wants to come home and receive his care in the states. He wants a doctor he can communicate with and nurses who can understand his requests and friends who can speak to him and calls that aren't subject to international fees. But his insurance is refusing the request. Medical treatment, they're arguing, is simply too expensive in America.

As a matter of economics, they're not wrong. In their seminal paper, "It's the Prices, Stupid," Uwe Reinhardt and Gerard Anderson marshal an impressive array of evidence to prove that the cost problem afflicting American health care is a per unit problem: It's not that we use more care, or use more technologically advanced care, but that we pay much more money for any given unit of care.

And that's really the driving factor behind all this medical tourism, isn't it?   We can chant over and over that "America has the best health care in the world," and that may be true to a degree, but the fact is that many other countries have modern, top-notch health care capabilities at much lower costs.  Of course, as the CNN article also points out, "The salary of a U.S. surgeon is five times that of a surgeon in India."   American physicians are also much better paid than in most developed countries:

Although the United States now has relatively fewer physicians per 1,000 population than the OECD median, its total national spending on physicians as a percentage of GDP is double the OECD median (2.9 percent in 1999, compared with an OECD median of 1.3 percent). [...] Physicians’ incomes are much higher in the United States than they are in other OECD countries. In 1996, the most recent year for which data are available for multiple countries, the average U.S. physician income was $199,000.27 The comparable OECD median physician income was $70,324.

The data is a little old, but I don't doubt the comparison is still valid.   This is something that most physicians would rather not talk about when we rant about the need for cost containment -- myself included! Physician compensation is not unique, however, in that all of the cost indices for the various service lines of US health care markedly outstrip their OECD counterparts.   So cost containment/reduction initiatives will need to be focused broadly, not just on the doctors, if US costs are ever to be brought in line with (or at least not get further out of proportion to) foreign countries.

Epidural Publicity

An alert reader pointed out this article on CNN:

But after hearing about Richardson's death, the McCrackens wondered if Morgan was really as OK as she seemed. After all, Richardson had been talking and lucid immediately after her fatal injury.

When they went upstairs to kiss Morgan good night, she complained of a headache. "Because of Natasha, we called the pediatrician immediately. And by the time I got off the phone with him, Morgan was sobbing, her head hurt so much."

She turned out to have an epidural, the same as Natasha Richardson, but did very well.

This is a weird case on several levels.  She wouldn't even have qualified for a CT scan in the ER based on generally accepted criteria.    The "lucid interval" is usually hours, not days.   And young people -- kids especially -- have tight heads and generally worse outcomes than middle-aged or older adults.   But it does highlight the value of education and public awareness.

Mother Nature's rebuttal

Know-nothing conservative wunderkind Bobby Jindal, tapped to respond to President Obama's NSOTU, used his national TV platform last month to sneer at "wasteful spending," including "$140
million for something called 'volcano monitoring.'" (scare quotes in original)

In a bit of karmic wonderfulness, Alaska's Mount Redoubt erupted last week, allowing the USGS to educate Governor Jindal: this is volcano monitoring.


Bonus geek points for the USGS: Redoubt eruption updates and ashfall forecasts have their own Twitter feed.   "Another explosive eruption of Redoubt volcano occurred at approximately 01:20 AKDT (0920 UTC). NWS reports a cloud top of 50,000 ft above..."

Volcanoes are cool.   Volcanoes that debunk right-wing canards are cooler.

You want socialism? We'll give you socialism!

Socialist senator Bernie Sanders (yes, he really does call himself a socialist) has introduced a single-payer health reform bill in the US Senate.   Kossack DrSteveB discusses co-sponsors and cost containment within the plan.

On the merits: fair enough, I can concede that single-payer does have the best potential for real savings, efficiency, and slowing down the growth in health care costs.   The downside is the inevitable government abuse of its monopsony power and subsequent downward pressure on physician reimbursement.

On the politics:  I don't want to be dismissive, but this doesn't have a chance in hell of becoming law.   Even the moderate consensus-based compromise plan will be a herculean task.   But it does have its use -- a bit of pressure from the left to encourage Senate leaders to keep the public plan as a viable part of the final health reform package.  This is particulary nic in light of recent comments by Senator Baucus, as (sort of) reported by Time's Karen Tumulty:

The insurance companies hate [the public plan], saying it is would be unfair for them to be forced to compete with the government. Many health care experts, however, argue that this provision is crucial, as a means of holding down health care costs. [...] Conservatives oppose it as well, because they see it as a first step toward a Canadian-style single-payer system.

What Baucus had to say will not give much comfort to those who support the idea of a public plan as it is presently being proposed. He strongly suggested that its main value, at this point, is as a bargaining chip to get the health insurance companies to agree to other things that reformers want to see:

"Essentially, it's to keep it on the table to encourage the private health insurance industry to move in the direction it knows it should move toward—namely, health insurance reform, which means eliminating pre-existing conditions, guaranteed issue, modified community ratings.  It's all those actions that insurance companies must take in order to provide affordable coverage. And the public option helps encourage the private companies to move in that direction, because they're worried. We might have to modify the public option to get enough votes. I hear some concerns among Republicans about the public option. The main purpose is to keep the health insurance feet to the fire."

I think it is essential that there be a public plan to force the insurance companies to compete on cost, customer service, and efficiency.   And that there be private plans to force the public plan to compete on the provider side with fair payment rates.   Talk like this of the public plan option as a bargaining chip does cause me some concern.   So, while it may be politically DOA, it's not altogether a bad thing for a purely public plan (single payer) to be emerging on Baucus' left flank.  

Wow this is cool

“208 OSEOsidades” by Saúl Hernández

Lots more mini-skeleton sculptures at the site.

Via Street Anatomy (where else?)

Velocity tracking

One of the metrics we monitor at our practice is the speed with which monies are collected.  Mostly this reflects on the performance of the billing company.   Generally it's a good thing to know how many "Days in AR," or days of charges still in the accounts receivable.   Low numbers are better, reflecting less "inventory on the shelves" and a shorter time from service provided to payment received.   This number can, however, be "gamed" if the billing agency were to move delinquent accounts off the books rapidly.   Ideally, they will rapidly write off the obviously uncollectable accounts (i.e. homeless patients with no billing address, charity cases, and the like), while keeping the accounts that have potential on the books and working them to collect what they can. 

One other fun thing to do is compare the payers against one another to see who's paying in a timely manner and who is not.  (Widen the browser window or click here to see the full image.)
Your mileage may vary.  Our state is an aberration in that traditional Medicaid is a very fast payer; compare that to Illinois, where they are eight months behind.   Of course, we joke, it doesn't take very long to pay nothing!  

You can see that, as is typical for most large billing agencies, Medicare is generally the fastest, with 70% of accounts paid in 15-60 days, and less than 20% aging beyond 90 days.   All the commercial agencies underperform, with fewer accounts current, and many more accounts >90 days old -- these usually result from denials, requests for more documentation, subrogation claims, and pure orneriness.  Auto claims and Worker's Comp, unsurprisingly pay the slowest, involving as they usually do lots of third-party liability and often requiring investigation.

Bear in mind that the vast majority of the revenue will in fact come from the first 60 days; claims that go over 90 days are rarely in fact paid.  The private insurers count on this -- a claim delayed is a claim denied.  Also, we are non-aprticipating with many of the commercial payers, which also tends to slow things down, since the common practice is to send the check to the patient, who then (we hope) will forward it to us.

The utopian dream would be a payer that had the speed & efficiency of Medicare with the payment rates of the privates.  

Dream on...

This is just insane

But well worth the read:

Life in the Fast Lane -- The Mark of the Beast

The man’s eyes were a cold blue deeply set above a bedraggled beard. Scarred knuckles at the ends of tattooed arms hung from a bare torso that bore the stigmata of a lifetime of violence - teeth marks, cigarette burns and various healed gashes and punctures. In another time he might have been seen leaping from a longboat onto frozen foreign sands or gnawing on a shield in a berserker frenzy.

Dayhawks

Vijay links to an interesting point on the growth of teleradiology:

The dayhawk phenomenon has grown out of hospital satisfaction with the rapid service hospitals receive on outsourced off-hour interpretations by nighthawk teleradiology groups. Hospital administrators and referring physicians have begun to wonder why their local radiology groups cannot deliver the same level of service for daytime radiology reads that they are receiving from nighthawk groups.

I agree with Vijay that smaller radiology groups will probably lose out, but not because of defensive medicine, as he posits.  I think it is just the economy of scale -- that larger groups with centralized reading facilities are better able to staff nights, weekends, and specialty reads.  As radiology interpretive services becomes more and more a commodity, that trend will accelerate.   We're lucky, in that our tele-radiologists are the same local docs we have always had, just grown up a bit and providing services to a dozen local hospitals.  They came close, though, a few years ago, to losing their contract at our large hospital because of terrible customer service.   It was that threat that forced them to re-engineer their processes and become an absolute paragon of superior service.   Now, they are so good that I often have a dictated report on the chart before the patient is physically back from the scanner.

I wonder, though, how hospitals that outsource to regional or international vendors manage the services that require an on-site radiologist -- fluoro, ultrasound, and other radiologic procedures.   Some could be performed by IR, but a lot of smaller hospitals don't have full-fledged IR services.   It's a big risk, I think, for a hospital to completely demolish its local radiology capacity.

I hate spam

Got hit with a major comment spam assault today.   Over a two-hour period, I got over a hundred "comments" full of links for chinese-language pages.   Weird.  And they weren't, as far I could tell for WoW gold, viagra, or even porn (which at least is a sort of universal language).   I think I cleaned them all out, but if you see any still there, let me know.   It was a major PIA.   If this happens again, I may have to look at better spamkiller apps.   Anyone know of ones that work for blogger?

Cootie Vaccinations

If you don't read the Bad Astronomer, you should.   And it looks like, courtesy of the BA, I have a new webcomic to add to my aggregator.

Click the image to see the full toon.

Sandan

Passed the test.  Video of the kata can be seen here, if you like.   Bonus points if you can spot when I nearly hit Tim in his head with the Bo (staff). 

Now I don't have to test again for (at least) three years...

What I'm drinking tonight

Brutal Bitter Ale - Rogue Ales Brewery - BeerAdvocate

Poured with a thick and persistent head. Opaque caramel colour with moderate carbonation. The initial esters were a potpourri of floral and fruity notes. I kept sniffing it to see how many things were hidden away in the aroma. Very rich.
Flavour is astonishingly rich and fruity. Grapefruit abounds but also a hint of toffee maybe or caramel that prevents too much puckering. This is a massively flavoured bitter. The label says it's Hedonistic and it is. It's almost too much flavour which makes the drinkability score lower but everything is balanced perfectly. Awesome.

We're out of Dilaudid

Apparently there's a national shortage.  Our frequent flyers are unhappy.   "But doctor, morphine just doesn't work for me..."

We might as well hang out a sign and close down the ER till stocks are replenished.

Professionalism

I've long been on record as being a fan of the police.   Not these guys, though I liked them too.   But the Garda, the gendarmes, the thin blue line.   And not just because they let me off of tickets on a semi-regular basis.   I work with them on a more or less daily basis, and that experience has led me to really appreciate and respect the job that they do.  

The other night, the local boys brought in a patient for a psychiatric evaluation.   He had been suicidal, and had attempted to shoot himself.   Something had gone awry; perhaps the gun has misfired, and perhaps he just missed.  It wasn't clear.   But he barricaded himself in his house when the police responded, and he had fairly clearly been attempting suicide by cop.   He remained armed, and was deliberately provocative and uncooperative.   In many cases, this will result in a police shooting.   But the fact that the police knew in advance that he was suicidal, and that he repeatedly asked them to shoot him, led our local police force to take a carefully restrained approach to the situation.

Just for reference, for those readers not acquainted with law enforcement practices, typical police procedures when confronting an armed individual does allow deadly force, with a fairly low threshold for action.   If a suicidal person is holding a gun in his hand, he is as capable of pointing it at the police as himself, and the police will shoot to protect themselves and their fellow officers if they must.  "Make sure you go home at the end of the day," is not just a cliche in law enforcement.   So, to be clear, the situation that our cops were in would have justified deadly force with no question whatsoever.

But they did not shoot him.  They remained under cover as much as they could, and did their best to negotiate with him.   After much effort, this was unsuccessful, and he was disarmed and taken into custody with a combination of a K-9 team and a much-maligned less-lethal weapon.

Truth be told, the dogs did a fair bit of damage, and I had some suturing to do to fix up his face and arms.   The patient (drunk, of course) was extremely upset that they has sicced the dogs on him, and was completely oblivious to how close he had come to perishing in a hail of bullets.

The thing that struck me, seeing the patient after the fact, was what an incredible job the police had done in saving this person's life.   He would have shot himself, without intervention, and could easily have killed a police officer.   This could easily have been the leading story on the evening news.   Had they shot him, no inquest board in the world would have faulted them.   But they held their fire, remained safe, and managed to defuse the situation with a combination of perseverance and creative thinking.

That's professionalism, and you've got to respect it when you see it.

What I'm drinking

Rogue Brewery's Deadliest Ale

Endorsed by Captain Sig himself.  Yummy.

Colbert Nation Strikes Again

Space Station Colbert? : ScienceInsider

NASA's online contest to name a new room at the international space station went awry. Comedian Stephen Colbert won.

The name "Colbert" beat out NASA's four suggested options in the space agency's effort to have the public help name the addition. The new room will be launched later this year.

Awesome. The other thing that makes me laugh is that among the other leading write-in options was "ubuntu." Geeks rule.

My prediction is that they will go with "Serenity," itself a nod to geek culture, but the name Colbert will be featured somewhere on the module and Colbert will make a big deal about it, generating some great PR for NASA.   At least that would be the smart thing to do.

Follow-up on Natasha Richardson

Regarding actress Natasha Richarson, who died after an apparently trivial fall, the medical examiner issued his report showing that the incident lesion was an epidural hematoma after all. Not a huge surprise, in that the "lucid interval" was so classic.

It reminds me of a case I blogged last year, about a young skier who arrested on the hill. In that case, I heard the post-mortem showed that the minor fall which had preceded the arrest had caused a fractured clavicle. The bizarre element there was that the clavicular fracture fragment had lacerated the subclavian artery (a complication which I had never even dreamed of) and the patient had exsanguinated into her thorax. And every year a few skiers die of asphyxia after falling into tree wells. Just last Tuesday I helped dig out a snowboarder who had gotten himself stuck in one -- fortunately head-up.

There are so many stupid ways to die out there -- not stupid in the sense that the victim did somethign stupid, but stupid in the sense that some little trivial thing suddenly winds up much bigger and worse than you would ordinarily expect. Sad.

Back on the original point, the Director of Trauma Services for McGill University Health Center, Montreal's trauma center, recently said that the lack of helicopter transportation may have been critical in her injury progressing beyond survivability. I think that may be an overstatement in this case. Certainly the 2-1/2 hour ground transport to Montreal didn't help matters, but the 2 hours' delay in getting to the first hospital put them so far behind the eight-ball that it would have been very difficult to save her in any case.

Having said that, it does kind of boggle my mind that they don't have some sort of medevac capability in a province the size of Quebec. I trained in Maryland, and for that fairly small state there were no fewer than eleven Dauphin helicopters operated by the State Police for EMS transport. And Quebec doesn't even have one? Amazing. Before the "single-payer sucks" advocates jump on this, I would like to point out that in Maryland and many other localities, EMS is paid for primarily out of tax coffers, not by the insurers. This is not about single-payer.

Others commented that it was kind of funny that she wasn't taken to a trauma center straight away, and suggested that too, is a failure of Canadian health care. I would like to point out that would be common at many US ski resorts. I work at times at a level 4 trauma center that is the closest receiving facility to a major ski area, and we get all of the trauma from the resort. Most of it is simple orthopedics, and we are well equipped to handle that. Anything more dramatic gets stabilized, bundled up, and shipped to the local level 2 or 1 center, as appropriate. Except we have helicopters for when it is necessary.

NYT graphs the recession

Click through to the NYT for the fully interactive map. My county has seen its unemployment double over the last year. Also, bear in mind that the second-lightest color goes all the way up to 10%, which is itself fairly high. [corrected stupid error, thanks to a commenter.] It's pretty amazing how many counties are all the way in the 15%+ unemployment range already.

Christian coloring book

Via Raptureponies:


I have no idea if this is real, and actually kind of assume it's a joke (the coloring hints are a little over the top).  But I love the image.   How cool is Jesus?   He's so cool he rides a fricking DINOSAUR!   Looks kind of like a Deinonychus, I would guess.  I do wonder how he gets that bit and bridle on without getting savaged.  'Course, he's got the power of omnipotence, so it's probably easy for him.

I love the internet.

(I take that back -- looks like Deinonychus was smaller than I recollected.  Maybe it's a small Utahraptor that he rode when he visited the proto-Mormons in America.)

Medical Malpractice reform under Obama?

Don't count on it.

Open Left:: Obama's Donor Base--A Reminder By Industry

Rank Industry Total

1. Retired $44,524,860.00
2. Lawyers/Law Firms $42,861,936.00
3. Education $22,342,123.00
4. Misc Business $15,457,514.00
5. Securities & Investment $14,442,282.00
6. Health Professionals $11,532,962.00

Source: Open Secrets.

Though perhaps I'm being too nihilistic here. McCain's list looked pretty similar -- though the numbers are much lower due to his decision to funnel most of his campaign contributions through the RNC. Perhaps the real take-home message is that lawyers and their lobbies are better organized and better funded that the physician lobbies, and that lawyers are more politically engaged. That was certainly our experience a few years ago in our state, when we tried to get med mal reform passed via initiative. The local ATLA affiliate ran rings around us in fundraising, and though our polling looked good for tort reform, after the lawyers' lobby saturated the airwaves with misleading ads, the initiative failed by a narrow margin.

I should point out that every time I mention ACEP or the AMA on this blog, I get a comment or an email from a doc who complains that they "don't represent me" and so they will never belong to it. To which I say, fine, that is your prerogative, but the consequence is neutered advocacy groups with very little clout in the nation's and states' capitols.

Bottom line: if physicians want to be better represented in policy and politics, we need to be better funded, better organized, and better engaged.

(F)lannigan's Ball

Dropkick Murphy's

Brilliant. Uninterrupted audio version here.

G'night.

Ambitious or Crazy?

It's not like comprehensive health care reform and universal coverage was going to be a simple thing.   The costs are just staggering -- the consensus estimate has been $100 billion per year, with some estimates running to $150 Bn annually.   The unlikely bedfellows are growing more and more uneasy, as unions, businesses, and insurers begin to eye one another warily.  The interest groups, including the physicians' lobbies, are greedily (and apprehensively) eyeing the pile of money and wondering how it can be divided up.   Add to that the surprising and earnest acknowledgment from the administration that health care costs must be contained for this to work.

So it's not as if Obama was setting himself up for a small challenge in undertaking reform.

But did he really have to go and open this can of worms?

The Obama administration and key congressional Democrats are taking a hard look at the nation's medical malpractice system as part of a broader health care overhaul.

Wow.  As if there weren't enough possible roadblocks to health reform, ya gotta throw this in, too?

To my surprise, there are signals from influential democrats that malpractice reform may actually be on the table in a meaningful way:

• President Obama told business leaders last week that ideas to save money like "medical liability issues - I think all those things have to be on the table."
• "It's an essential piece for there to be enduring reform - reform that will stick and will get a significant bipartisan vote in the United States Senate," said Sen. Ron Wyden (D., Ore.)
• Senate Finance Committee Chairman Max Baucus (D., Mont.) cites costs including fast-rising medical malpractice insurance premiums and so-called defensive medicine, [and] has proposed giving states grants to develop alternate litigation, such as "health courts" whose judges have health care expertise.
• Rep. Rob Andrews (D., N.J.), who chairs an Education and Labor health subcommittee: "It's hard for me to imagine a result that gets to the president's desk that doesn't deal with the medical malpractice issue in some way,"

The AMA takes a predictable position on the matter:   “If the bill doesn’t have medical liability reform in it, then we don’t see how it is going to be successful in controlling costs,” said Dr. James Rohack, president-elect of the AMA. “Why spend the political capital and energy in passing a bill if it is not successful?”  And in response, the ATLA (Orwellianly renamed the American Association for Justice) is circulating a 29-page pamphlet opposing its inclusion.

My suspicion is that this won't make it into the final package -- it's too explosive, and has too much potential to derail the whole thing.   However, its inclusion might be a useful tool to co-opt the AMA and suspicious physicians' lobbies into support (or at least to mitigate their resistance).  It may also be a bargaining chip to bring along some republican support.

Quite frankly, the biggest argument against inclusion of med mal reform in the "cost savings" part of the plan is that it is not entirely relevant.  Estimates vary wildly as to the systemic costs of liability and defensive medicine, but I suspect that even the dream package of med-mal reform would not realize the huge savings necessary to include it as an integral element of cost control.  Accept for the sake of argument the higher estimate, that the costs are $200 Bn annually, which includes defensive medicine.   Is it reasonable to expect that the culture of aggressive testing, CYA practice, and the stigma of missing a diagnosis will just evaporate?   I doubt it.  As long as there exists the idea of these "bad doctors" who hurt patients, doctors will still fear being labeled and punished, and practices will change little.   There may be some marginal saving to be had there, but it won't be $200 Bn, and probably not a tenth of that.   Furthermore, if there were no-fault injury compensation funds established, that would indeed go a long way towards limiting the infrequent and egregious jackpot jury awards.   But that might be balanced by the larger number of smaller payouts for cases which occur today but never see the light of day in the high cost-to-entry litigation system we now have.  If malpractice insurance premiums are actuarily sound (a big if), then premium prices should be minimally affected by that sort of cost-shifting.

Perhaps I'm being too nihilistic.   It's inarguable that the liability system is broken and needs to be fixed.   Comprehensive reform presents an opportunity to sever the Gordian knot.   Maybe Obama is crazy taking it on, but maybe, just maybe, he's crazy like a fox.

Let's hope.

My 0.04 seconds of populist outrage

Via the Washington Monthly:

AIG MEASURE CLEARS HOUSE: The House passed its measure today to recoup the controversial AIG bonuses. While there was some question going into the vote as to whether the two-thirds needed for passage would be there, the bill was approved rather easily
[...] The bill would place a 90 percent tax on bonuses paid out by firms receiving at least $5 billion in bailout money. The tax would apply to individuals and families with overall income exceeding $250,000..

Good. 

We now return you to your regularly scheduled programming.

Modern Capitalism, explained by Calvin

I had forgotten this one (h/t Crooks & Liars).  See here for the complete strip, and consider whether this accurately reflects the state of modern American capitalism.

Kinda spooky, isn't it?

Obama and Health Care (Inside baseball)

Jonathan Cohn at TNR has a nice piece today about how Obama himself was instrumental in keeping cautious advisors from killing health care reform before it even got off the ground. It's titled, appropriately enough, Stayin' Alive

It was amid these conditions that the debate over the budget got underway. A series of formal and informal discussions unfolded in the White House and outside it, and Obama was not present for all of them. Particularly in Obama's absence, the voices of the skeptics often predominated. "It was scaring the hell out of the rest of us," says one of the advisers who favored more aggressive action.

And health care, in the end, might have gotten pushed aside--except that one very senior official in the administration kept insisting that it stay on the agenda. That official was Obama himself. Repeatedly, the president made clear that he was not abandoning health care reform.

Nothing earth-shaking here, but it's an interesting window into the operations of the White House, and the management style of this President.

Talk and Die

Kevin has a bit of speculation about actress Natasha Richardson, who reportedly, suffered a head injury during a ski lesson in Canada.   She is universally described as seriously ill, with some reporting that she is brain dead.  Hopefully that will turn out to be an exaggeration.

It has been noted numerous times that while she was not wearing a helmet, she was on a beginner's hill having a private lesson when she fell, with the implication that she was not engaging an a particularly risky activity.  True enough -- the serious injuries only rarely occur in these settings. 

But the really key thing to recognize in these injuries, is that although snow is soft, ice is hard, as hard as concrete, and even a low-risk mechanism of injury such as a fall from a standing position is more than sufficient to crack the skull.   A fall on skis, or ice skates (especially ice skates) needs to be recognized as a high-energy mechanism of injury.    This is why I'm such an aggressive advocate of wearing a helmet while skiing or snowboarding -- one of the hospitals where I work is the closest to a regional ski resort and we see lots of head injuries there.   Fortunately, helmets are fashionable wear for the teens these days -- they like it because it makes them look "extreme."

As for the mechanics of the "talk and die" syndrome, the blogger at Kennedy's Tumor has a differential:

1. Epidural Hematoma
2. Subdural Hematoma
3. Subarachnoid hemorrhage

To which I would add:
4. Cerebral contusion
5. Diffuse axonal injury

I recently wrote about a young man with nonsurgical head injuries who surprised us by dying.   He differed from Ms. Richardson in that he was clearly concussed, while media reports describe her as asymptomatic for the first hour or so.   But who really knows?

I'd favor an epidural hematoma, myself, as the most likely cause of the problem, but it would be anything.   I'd differ from Dr. T in that I think a non-traumatic SAH is possible but pretty unlikely -- we know she fell and it seems needlessly complicated to presume a pre-existent lesion.  Ultimately, though, it's a huge tragedy for all involved, and very sad even if she does pull through.  The take home message is for everybody who straps on skis to get yourself a goddamn brain bucket and wear it religiously.  I do -- and it's saved me from a few concussions (or worse).   Better yet, it keeps your head warm and keeps your ipod ear buds in place.  It's a win-win!

UPDATED:
Ms Richardson is now confirmed to have died.  My condolences to her family.

Shout out for a quilter

Suture for a Living: Double Irish Chain Baby Quilt

I was stunned when the generous Dr Bates offered to make a quilt for my baby daughter, and all the more stunned when it arrived -- not stunned that it arrived, but at how lovely it was.  See for yourself:


I don't know the first thing about making a quilt, but I can recognize something beautiful and well-made when I see it.   The only conflict we have is that, although it's clearly meant to go in her crib, and be used and loved, we are tempted to frame it and hang it on the wall as a work of art!

And she got the whole Irish thing in there too.  It means nothing to me, but I told my mom, a crafter in her own right, that it was Irish Chain and she nodded knowingly and said that it was a nice pattern.

Thanks so much, and if that whole plastic surgery thing doesn't work out, I've an idea of a second career for you...

The Death of Print Media

The Seattle P-I is set to publish its last edition Tuesday

Bummer.   It was the better of the two papers in Seattle.   Though, truthfully, I'm more or less ready to stop reading the dead-tree editions anyway.  I've always enjoyed sitting down with the paper and coffee, but except for the comics, I've been getting all my news on the web for the past few years.   Then both local papers recently shrank quite a bit and rolled several sections together.   I suppose it made sense from a cost perspective, but seemed destructive from a business perspective -- your business model is outmoded and the customer base is shrinking, and you think that giving us less product is the way to become profitable again?   Sheesh.

For that matter, the only reason I can think of to keep getting the print editions is as a sort of civic-duty subsidy to keep local investigative journalism alive.   Which isn't much of a reason, I must admit.

I don't think this will be the last major publication to shut its doors.   Kind of sad -- the end of an era.  

I'm Back and I'm Bald

I'm home, and much fun was had by all. More importantly, I've raised over $8,000 for pediatric cancer research -- so far. Donations are still open through, well, they're actually welcome any time! Nathan's Network raised $19,000, and Baldrick's en masse is up to $8 million -- so far.

The video below is my shaving: I'm on the left.  In the center is team member Carlos, and on the far right, poorly seen in the video, is team member Maria, who I particularly respect as brave and beautiful for shaving!  

St Baldrick's 2009 from Shadowfax MD on Vimeo.

Enjoy the video, but be advised that if you watch it, you are morally obligated to donate! Otherwise, you're just a common thief!

I joke -- enjoy the clip, but if you can, it is not too late to make a gift:

Click here to Donate

The consequences of the Economy hitting healthcare

Some folks wonder why the economy impacts health care, which seems on first glance to have an inelastic demand curve -- that if you're sick, your perceived need for health care should not vary based on the economy.   But that in fact is not the case -- patients/consumers are highly sensitive to economic factors in their health care consumption, and much of that is elective.   The NY times has a nice article on that phenomenon today:

Bad Economy Leads Patients To Put Off Surgery, or Rush It - NYTimes.com

The slowdown is likely to have significant financial repercussions. Elective operations are typically covered by private insurance plans that tend to reimburse hospitals and doctors at higher rates than government insurance programs like Medicare and Medicaid. As those payments dwindle, so do hospital profit margins and the resources to provide charity care to a growing number of uninsured.

“Elective admissions could represent only 9 or 10 percent of a hospital’s admissions and yet represent 25 percent of its bottom line,” said Michael A. Sachs, chief executive of Sg2, a health care consulting firm. “They’re the patients that subsidize the underfunding associated with Medicaid and Medicare patients and uncompensated care.”

This is consistent with what we're seeing at our facilities.  The ER's not terribly effected -- yet.  Volumes are up a tick, and the uninsured rate is up ten percent: overall the effect is minimal.   But our parent institutions are suffering badly from the above factors, and layoffs and severe budget cutbacks are the rule of the day.  Management is coping with it well, but these are indeed tough times, likely to get worse as the recession deepens.

Bald!

Better pics and possibly video to follow when able.

The Home Stretch

Well, with just over 24 hours to go before the shaving, I've raised over $7,000. I set an ambitious goal in this challenging economy, and have made it over 70% of the way there. I'm pretty happy with the results so far, bearing in mind that a significant fraction of donations come in after the event (and all the way till the end of the year). I may yet hit the goal.

For all of you who have given: I thank you, and look to see pics of my gleaming scalp soon. For those of you who have considered doing so, thank you for your consideration and indulgence.

This is a tremendously important cause, and even small donations are helpful. So please consider making a donation -- and there are collateral benefits. I was talking with our family priest and he told me that as a matter of doctrine, all donors to St Baldrick's go directly to Heaven, completely bypassing purgatory.* So you got that going for you, which is nice.

Click here to Donate


*Not Really.

Charlie Brown, re-imagined

If you're like me, you've probably spent a fair amount of time wondering, "What if Frank Miller had done Peanuts?"   Now you need wonder no more:

 
Brilliant.

Every single day I get down on my knees and thank my Noodly Creator for the glory that is the internet.

(h/t Crazy Andy)

Funny

By Mike Monteiro.   There's more to be had here.

Shilling for Baldrick's

Click here to Donate

My friend, Beth is a pediatric oncologist who is also the recipient of a Baldrick's grant towards here research on Medulloblastoma. I asked her to summarize for us what she is doing to develop effective treatments for this disease, the same one that took Henry Scheck's life, and she wrote this:

Brain tumors are the leading cause of pediatric cancer deaths, and medulloblastoma is the most common malignant brain tumor. Current treatments for medulloblastoma, when effective, often have lifelong side effects. A potential new drug called IPI-926 is currently in Phase 1 trials for adults with cancer, and is being evaluated preclinically in medulloblastoma. IPI-926 is active and well tolerated in preclinical models of medulloblastoma. It works by interfering with the Hedgehog pathway, a cellular signaling network, which is activated in many medulloblastomas. IPI-926 is a semi-synthetic derivate of the plant-derived natural product, cyclopamine, and it is orally administered.

Ptc1-null mice develop early and aggressive medulloblastomas, which cause bulging skulls and difficulty walking within weeks of birth. All 11 of the mice treated with placebo died from their disease by two months of age. In contrast, all 12 mice that received daily IPI-926 showed dramatic improvement. After only 2 weeks of IPI-926 treatment, all skull deformities and neurologic deficits resolved. Furthermore, IPI-926 significantly improved survival rates (p < 0.0001). All of the IPI-926-treated mice were alive and well after six weeks of treatment, after their placebo-treated siblings had succumbed to their disease.

IPI-926 leads to dramatic clinical improvement and significantly prolongs life in a mouse model of aggressive medulloblastoma. This work will be presented at the 2009 American Association for Cancer Research national meeting, and a manuscript is in preparation for publication.

It's a little jargon-y, which is understandable from one ensconced so deeply in her research, but the summary is this: they have a compound which shows some real potential for being an effective treatment for medulloblastoma! You go, Beth!

So, consider for a moment the potential that this research bears, and the possiblity that it might be scaled back, delayed, or shut down for lack of funding. If you can, please take a moment to donate to Baldrick's to support more research like this.

Word to the Wise

The Daily Show With Jon StewartM - Th 11p / 10c

In Cramer We Trust

Daily Show Full Episodes
Important Things With Demetri Martin

Political Humor
Economic Crisis

Don't fuck with Jon Stewart. He will make you look like a fool.

Seriously.

Gruntdoc blogged this

But it deserves another mention.

The Periodic Table of Awesoments

It's... well, it's awesome.

I mean, really, really awesome.

Be certain not to overlook the Noble Races.

Every day I get down on my knees and thank My Noodly Creator for the glory and wonder that is the internet.

Americans want more government involvement in health care

Or at least the option.

A recent poll by Lake Research for Health Care For America Now shows that there is "intense and widespread support" for the choice of a public health insurance plan, with 73% of voters favoring a choice of a public or private plan, including large majorities of Democrats and independents (77% and 79%) but surprisingly, even a high plurality of Republicans (63%).

A majority of respondents agreed that a public plan would spend less on profits, whereas only a quarter thought that a public plan would be "a big, government bureaucracy."   60% of voters thought that "if private insurers are really more efficient than government, then they won’t have any trouble competing with a public health insurance plan."

Think Progress reports that "According to the Commonwealth Fund, a public coverage program similar to Medicare would reduce projected health care costs by about $2 trillion over 11 years, and lower premiums by about 20% on average."

Worthless alerts

I know this has been blogged elsewhere recently, but I couldn't pass up the opportunity to chime in.   From the AMA news:

Doctors override most e-Rx safety alerts
E-prescribing systems' clinical decision support is "grossly inadequate," says a new study. But there are ways to stop low-severity alerts.

The latest example is a study of the electronic prescribing records of nearly 2,900 community physicians and other prescribers in Massachusetts, New Jersey and Pennsylvania. Nearly 230,000 times these doctors were warned about potential drug interactions, and 90% of the time they decided to proceed as if the alert had never appeared.

"The systems and the computers that are supposed to make [physicians'] lives better are actually torturing them," said Saul N. Weingart, MD, PhD, co-author of the study, which was published in the Feb. 9 Archives of Internal Medicine.

The results, Dr. Weingart said, do not show that physicians are recklessly ignoring warnings. Rather, too many of the electronic alerts are irrelevant to the clinical circumstances doctors face and the patients they treat.

"Given the high override rate of all alerts, it appears that the utility of electronic medication alerts in outpatient practice is grossly inadequate," the study said.

Yeah, no kidding.  We use the Picis system in our ER.  Overall, I love it, and it immediately improved my person productivity, and makes managing our ER easier and more precise.   EMRs I can take or leave, but an EDIS is essential, in my opinion.  Patient tracking, resource utilization, physician order entry -- it's all great.   But the med interactions are just useless. 

We convinced the vendor to turn off all interaction warnings except for "Allergies" and "Severe Interactions."   And yet, more than 90% of the interactions flagged -- closer to 99% in my experience -- are worthless and I click right through them.  On a recent shift, I made note of a few of the interactions that the system flagged:

phenergan-tramadol
cipro-tramadol
golytely-phenergan
ibuprofen-naproxen
robitussin-tramadol
tequin-phenergan
duoneb-sudafed
dilaudid-percoset
geodon-zofran
avelox-zofran

Argh.   This was just a small sample, the few that I bothered to write down.   Some of them are legimate, but still irrelevant.  A patient reports taking naproxen, and I want to give him a dose of ibuprofen in the ER.  Double-prescribing NSAIDS could cause an GI bleed, but a single dose is hardly a "severe" interaction.   Ditto with percoset and dilaudud.  Yeah, in theory it could cause additive respiratory depression.  So I get where some of these come from.   But the others are just dumb, and the fact that these are selected "severe" interactions just boggles my mind.

I lobbied the vendor to entirely shut off the interactions function, but they refused, citing liability.

So we click through, and hopefully the few real interactions won't get ignored because of the extremely signal to noise ratio.   I tried to argue with the Picis reps that there was actually a higher risk of a med error due to their poorly designed database, but that got no traction.

Super Users

At our hospital, they call the ED staff who have received advanced training in the use of our EMR "Super Users."   We all have administrator privileges and are expected to help other staff and trouble-shoot while we are in the department.

Apparently, it's also the new, politically correct, euphemism for what we otherwise call "frequent flyers."

KaiserNetwork reports about an interesting pilot program in Camden, New Jersey, which targeted just 35 frequent flyers super users who were responsible for over $1.2 million in hospital charges each month.  Through use of a "nurse practitioner, a social worker and a community health worker, the average number of hospital and ED visits each month for the 35 patients dropped from 61 to 37, and total hospital charges were reduced to $531,000."  The annual expense was about $300,000, which was probably far less than the losses the hospital was incurring through unreimbursed services by medicaid.

Intriguing...

(h/t DKos)

Headline of the Day

Government Insured Republicans Reject So-Called ‘Government-Run’ Health Care

Love the framing. Even though Grassley, Blunt, and McConnell reject the option of a public plan option in health care reform, none of them have dropped their health insurance through the FEHBP in favor of seeking a private plan on the open market. The FEHBP has been described as a model for a public plan. Apparently it's god enough for members of Congress, but too good to be offered as an option for the American public to choose from.

Who makes the decisions?

I pointed out the lovely sound bite the other day: "Who would you rather have making decisions about your healthcare - someone who has a profit motive for denying coverage and treatment, or someone who doesn't?" This prompted the immediate rejoinder from Peter: "You want the government to dictate to physicians what they are and are not allowed to do in the treatment of their patients?" and a similar sentiment from Anonymous (that guy is everywhere): "So you'd rather have people with political motives making decisions about your health care?"

And the answer, of course, is yes.

With some explanation:
When we talk about "decisions" being made (outside of the patient-physician relationship) we are talking about decisions regarding funding, or coverage -- more specifically the decision to deny coverage for a given procedure, effectively denying it to all but the very wealthy or the very committed. In an ideal world, these decisions would not be necessary -- we would have enough funds to cover every service for every patient who wanted it and no such "decisions" would ever be made. That, of course, is pure fantasy. In an ideal world somewhat closer to the real world, the decisions would be made on a basis of efficacy and cost-efficiency, with flexibility and with the best interests of patients first.

Can insurance companies be trusted to make these decisions in a neutral and unbiased fashion? No. Never. Not so long as they are for-profit organizations. A quick review of their recent history shows the degree to which their profit motive drives behavior ranging from the slightly sleazy to the illegal to the immoral:

Insurance companies have a long history of non-payment to providers for services rendered. One common tactic is to go through the medical record, or the claims submission form and find some minor error or omission and deny payment for the whole claim on the basis of that. Or they write "edits" into their billing software which will automatically deny payment based on certain criteria. For example, if the site of service is the ER, and the ICD-9 code is that for "Gastritis" then the bill is automatically denied, under the flimsy pretext that "Gastritis" is not an emergency and thus the requirement for medical necessity is not met. This practice was so widely abused that it prompted "prudent layperson" legislation in many states, but it still persists to some degree. The insurance companies know that a certain fraction of rejected claims will simply be written off by the doctor or paid by the patient, which is pure profit for them. Additionally, insurers will automatically bundle multiple services into a lower single payment, or substitute one service for another, without any justifiable reason beyond the fact that they can. More recently, there have been news reports about how the Ingenix database, designed to provide data on "Ususal, Customary & Resonable" charges was manipulated by its owner, UnitedHealth in order to systematically underpay physician for out-of-network services.

The shenanigans of health insurers, however, have not been limited to the provider side of the equation. Patients also bear the burden of the insurance industry's drive for profits. They will delay or deny authorization for treatments which doctors recommend, or impose difficult pre-authorization requirements for documentation and necessity, all in the hopes that a certain fraction of claimants will be deterred by the morass of administrative red tape and simply lose interest and go away. A procedure which is not performed is one they don't have to pay for, which represents increased profits for the health care company. It's important to recognize that this burden increases the cost of health care for everybody, as doctors and their staff have to waste their time jousting with the insurers seeking approval (which is often denied anyway). But the insurance companies don't care about this -- why should they? They are private actors in the system rationally pursuing their own self-interest. The system can be subjected to the death of a thousand cuts, so long as their individual bottom line is protected.

Unfortunately, they don't limit themselves to prospectively limiting care provided. There's good money to be made by retrospectively denying payment for care already provided! Much of this is accomplished on the provider side, outlined above. But there are some particularly egregious practices of retroactively reviewing the applications of patients who develop expensive health problems and rescinding coverage based on minor tyopgraphical errors or immaterial omissions.

These are not accidental events. These are not the isolated actions of occasional misinformed insurance claims representatives. These are the result of deliberate policy decisions of the industry at large: intelligent policies from the perspective of an organization which is trying to efficiently pursue its financial interest. They hire people who are trained to obstruct, delay, and deny payment for services.

You can see for yourself in this dramatic, unedited documentary footage of an insurance claims manager heartlessly abusing a client:

The same phenomenon, by the way, applies in various forms to not-for-profit insurers and self-insured administered plans. Their motives are slightly differently directed, but the profit motive is ultimately the same.

Medicare, on the other hand, is not guilty of any of the above abuses. They do deny coverage for some things -- certain observation admission, SNF admission without the magic three-day admission, etc. These may be bad policy, but they are set across the board, well-publicized, and applied fairly to all patients. If you need a colonoscopy, or some other garden-variety medical service, medicare is the best insurer to have from the point of view of authorization and payment, because it's simple and hassle-free. Why? Because they do not have the profit motive to make it difficult to access care.

Medicare is not perfect. Its biggest problem is that reimbursement is set at an unsustainably low level, and subject to political forces. The advantage of having a public plan (which would not be Medicare, BTW, but an entity analogous to the FEHBP) is that the public and private insurance plans would have to compete against one another. The private plans pay well, compared to medicare, and the public plan would have to compete on this basis to maintain provider networks. On the other hand, one might expect the public plan to have better customer service and access to care, and the private plans would have to compete on this basis to enroll patients.

Anon had asked about "political" motives entering into health policy decisions. It's hard to see this becoming an operative concern. I suppose reproductive health can be highly political, but the beauty of our government is that the civil servants tend to insulate the agencies from many of the political pressures of the day, and ultimately the government is accountable to the voters. While it's possible that a future republican government might try to cut back access to abortion or contraception, I just don't see that as being likely enough to militate against the public plan option. And, if it did happen, then consumers would flock away from the public plan back into private insurance.

Lotsa Chest Pain Today

Which I guess makes sense, because apparently Daylight Savings Time causes heart attacks.

Oh Noes! Teh Socialism!

Thank you, John Cole, for this useful bit of perspective:

The 2010 proposed rate of 39.60% = socialism.
The 2002-2008 rates of 35.00% = capitalist nirvana.
The 39.6% rate of the 1990’s = socialism.
Everything else = down the memory hole.

That Obama fellow sure is soaking the rich, isn’t he?

And I might add that the era of insanely high marginal rates included a number of years of robust economic expansion and a few recessions, as the normal economic cycles dictate.  I only mention this to counter the inevitable argument that higher marginal taxes are economic poison.

50 reasons to reject evolution

Funny:

1.) Because I don’t like the idea that we came from apes… despite that humans are categorically defined and classified as apes.

2.) Because I’m too stupid and/or lazy to open a fucking book or turn on the Discovery Science Channel.

3.) Because if I can’t immediately understand how something works, then it must be bullshit.

4.) Because I don’t care that literally 99.9% of all biologists accept evolution as the unifying theory of biology.

5.) Because I prefer the theory that a (insert god of choice) went ALLA-KADABRA-ZAM MOTHAH-FUCKAHS!!!

6.) Because I can’t get it through my thick logic-proof skull that evolution refers ONLY to the process of speciation, not to abiogenesis, or planet formation, or big bang cosmology, or whether God exists, or where they buried Jimmy Hoffa, or why the sky is blue, or how many licks it takes to get to the center of a fucking Tootsie Pop.

Read the rest over at Deviant Art.

Science is cool

DarkSyde has a cool science sunday today.   Go read about the Kepler mission to detect even more extra solar planets.

Don't forget

I almost did.

Not a bad time to check your smoke detectors and carbon monoxide detectors, too.

Cactus 1549

The flight, animated, with the audio. Very cool.

Isn't it curious?

That the only thing that stops the vomiting in Cyclic Vomiting Syndrome is dilaudid?

This seems very consistent from patient to patient.  Also, the affective component seems pretty consistent part of the disorder as well.

Just an observation.

Sound Bite

Why we would benefit from a public (government run) health plan option:

"Who would you rather have making decisions about your healthcare - someone who has a profit motive for denying coverage and treatment, or someone who doesn't?"

From the comments over at Political Animal.

The least surprising thing I've read today

Via Scanman:

GE, Siemens Fight Obama Plan to Cut MRI, X-Ray Costs

March 6 (Bloomberg) -- General Electric Co. and Siemens AG, the biggest makers of medical imaging machines, say President Barack Obama’s plan to slash spending on the use of MRIs and X-rays threatens patients, and they’ll lobby Congress to block it. 

I'm astonished.   Wait, no, that's not the right word.   What's that thing that's the opposite of surprise?   Never mind, it'll come to me later.   The next thing you'll be telling me is that PhRMA is going to opposed Obama's proposal to cut prices of prescription drugs.   What?  That already happened?   Who'd have thunk it?  (In fairness, Tauzin has also made conciliatory noises, too.)

This is by far going to be the hardest part of health care reform.  There's a multi-trillion pile of dollars on the table, and every single interest group is very very interested in maximizing their share of the pile.   The AMA will argue for increased medicare and medicaid reimbursement.   The nurses associations are requesting increased investment in nursing resources.  The insurance lobby is trying to tilt the table in favor of insurers.   In short, any organization that can make a half-way reasonable case for it will opportunistically demand higher levels of funding, and any interest that winds up on the de-funding list will scream to high heaven and work like hell to stop it.  And we haven't even gotten to the internecine warfare of primary care doctors vs specialists!

The advantage of comprehensive reform is the "blank slate" opportunity to make sweeping, fundamental change.   The risk is that the process is such a free-for-all, so chaotic, that it's hard to predict what the final product will actually look like, once the hard decisions are made in the mileu of all the horse-trading, uneasy bedfellows, and shifting alliances. 

These guys do not pull their punches

Watch Prank War 7: The Half Million Dollar Shot on CollegeHumor

Hysterical, and truly cruel.   And, do not feel bad for the guy who got laughed at by 25,000 people.   He so richly deserved it:

Watch Prank War: The Yankee Prankee on CollegeHumor

That's just vicious.  Hysterical, but vicious.   These videos are not safe for work, by the way, in that you will laugh really loud and get fired. See the full prank war series here.

(h/t Ackerman)

Everyone's blogging it

The Daily Show With Jon StewartM - Th 11p / 10c

CNBC Gives Financial Advice

Daily Show Full Episodes
Important Things With Demetri Martin

Political Humor
Joke of the Day

So I might as well, too.   Pretty damn funny.

Newsy day today

And I'm just too tired to blog it all.   There are like a million synopses of the Obama health summit out there.   Ezra Klein has some good wonky stuff that I'm too tired to read in detail.

A couple of things that jumped out of Google reader at me:

Obama wants health care reform by the end of this year.  His tone was inclusive but not weak.  He clearly is drawing a line in the sand that he won't allow obstructionists to hijack the debate:

I want to be very clear at the outset that while everyone has a right to take part in this discussion, no one has the right to take it over.  The status quo is the one option that is not on the table.  And those who seek to block any reform at any cost will not prevail this time around.

But there was a pragmatic streak:

Each of us must accept that none of us will get everything that we want, and that no proposal for reform will be perfect.

On the public plan option, Grassley questioned whether the government would be an unfair competitor, but Obama defended its inclusion (color me relieved).   McConnell suggested that this was one element of the plan that the GOP simply would not compromise on.   I've got to say that this is pretty transparently disingenuous.  As David Sirota asks, "If the free market is so marvelously awesome, shouldn't it have no problem winning a health-care competition with a government-run program?"  I mean, isn't it conservative mantra that private concerns will always be more efficient and more effective than government bureaucrats?  Perhaps they're just worried that if the public program proves cheaper and easier than the private insurers, it would disprove a core tenet of conservative philosophy.  Frankly, it's a toss-up which will win.   The public plan will have no execs to pay, shareholders to pay, and minimal advertising costs.  It will have some economies of scale.   But the big insurers have the same economies of scale, and will aggressively try to select out the healthier customers.   Will the public plan be bogged down by adverse selection, or will it prove cheaper in the end?   I'll be interested to see -- and the market will decide!

Interestingly, Rep Joe Barton (R-TX) made some rather conciliatory noises.  A potential thaw in the House GOP?  I'll believe it when I see it.

Gupta Out

As predicted.   Speculation is that he didn't fancy the financial transition from million-dollar teevee doctor to a civil servant's salary.   Others suggest that with Daschle out he figured that he wouldn't have any influence in the health reform process.   Either way, no great loss.

So what's Howard Dean up to these days?

Everyone's blogging it

The Daily Show With Jon StewartM - Th 11p / 10c

CNBC Gives Financial Advice

Daily Show Full Episodes
Important Things With Demetri Martin

Political Humor
Joke of the Day

So I might as well, too.   Brutal.   And pretty damn funny.

Case study in the need for health reform

Time's Karen Tumulty has a great piece up today about her family's experience with the health insurance industry.   Go read it.

Some key points:

• Insurance companies are evil.   This is a pretty classic case of a company retroactively canceling a policy because the policy holder developed an expensive condition.   Health care reform, with guaranteed issue and community rating will go a long way towards restraining the bad behavior of the insurers.
• Underinsurance is as serious a problem as uninsurance.   This patient did the right thing (as far as he knew) -- he paid for private insurance, high-deductible, out of his own pocket.   It turns out that he bought the wrong policy for a number of reasons.   Even if Assurant had not canceled his policy, when he hit his next renewal date, he would have been freshly underwritten with his new chronic condition, and the cost of renewing the policy would have been well beyond his means, or would have been excluded as a pre-existing condition.
• Texas is not a state to live in if you are poor and sick.  25% of the population is uninsured and Medicaid only covers those making less than 21% of the poverty line!   Holy crap.   So much for compassionate conservatives.
• Preventative care saves both lives and money.   This is a great case study in which a patient may wind up falling out of the work force, hurting the economy and becoming a ward of the state, because of his chronic disease.   Not knowing his diagnosis, it's impossible to say that in this case preventative care would have kept stage 1 or 2 chronic kidney disease from progressing to stage 3 or 4, but across all comers it is certain that significant numbers of patients will benefit.
  
• The uninsured really get screwed with health care costs, when they have to pay the gross charges instead of the negotiated rates given to insured patients and medicare patients.  Of course, most don't pay, but it adds to their economic burden anyway and accelerates the slide towards bankruptcy.
• Half of bankrupties are in part due to medical costs.

A timely article, well-written, and full of insights into the current reform debate.

04 March 2009

Beer Pong gives you Herpes

The Colbert ReportMon - Thurs 11:30pm / 10:30c

Beer Pong Herpes Outbreak

Colbert Report Full Episodes
Political Humor

Rap Battle
Joke of the Day

Or maybe not.

I'm So Sorry

Have you apologized to Rush yet?

I got nothin'

But the interwebs tell me that Obama has some sort of health care thingy tomorrow (on CSPAN even!) during which he will articulate the following general principles for health care reform:

• Guarantee choice of health plans and physicians;
• Making health coverage affordable;
• Protecting families’ financial health;
• Investing in prevention and wellness;
• Providing portability of coverage;
• Aiming for universality;
• Improving patient safety and quality care; and
• Maintaining long-term fiscal sustainability.

The verbiage there makes me worry: "Aiming" for universality?   Dammit, Barack, this is no time for incrementalism!   Go for the gusto, or at least stake out your territory early in the negotiations.  Sheesh.

Also concerning was the absence of a public plan option in Obama's budgetary framework.  Howard Dean argues that a public insurance option is essential to the health reform effort.  I recall that this was still a point of contention in the Workhorse Group, so that may be why it is missing.  Let's just hope that Obama isn't backing off universality and the public option before the discussions begin in earnest.

Modern Healthcare vs ER Docs

May you be fortunate in your enemies, the old saying goes.

Apparently, we are.

There's an op-ed published Tuesday in a throwaway rag called Modern Healthcare, written by its editor, Dave Burda, it's a piece of work. Such a magnificent combination of ignorance and idiocy I haven't seen outside of Deepak Chopra's web site. It begins:

As you read this, special-interest groups are crawling over each other in our nation’s capital to grab their share of federal bailout money, using the current economic crisis as justification. One of the more distasteful displays of self-serving behavior is being put on by the American College of Emergency Physicians. The Washington-based group is manufacturing a crisis to ensure the full employment—and added reimbursement—of its more than 25,000 members. We urge federal lawmakers to look beyond the group’s alarmist rhetoric and kill the proposed Access to Emergency Medical Services Act before it even gets a hearing.

It's hard to know where to start, and this is only the lede. Apparently, Mr Burda has never heard of the Institute of Medicine's report, "Emergency Care: At the Breaking Point," and he's missed the Emergency Medicine Report Cards issued the last two years running. It's a manufactured crisis! (Shades of Phil Gramm's "mental recession"?) But perhaps I'm being too harsh -- it's not fair to expect him to know about every little ongoing collapse of a major health care sector. He's only the editor of Modern Healthcare magazine!

And added bit of evidence that Mr Burda couldn't find his ass with two hands and an ass-finding device is the implication that ACEP in trying to "ensure full employment" of its members. Um, what? Seriously? The field is understaffed by 40% -- over ten thousand ER docs short. There're no ER docs on the unemployment rolls -- quite the opposite; there are recruiters being paid $25,000 a head to put ER docs into positions.

Maybe he thinks we're sitting around in empty ERs twiddling our thumbs. Well, given that ER volumes have skrocketed by a third over the last decade (in concert with a contraction of the number of operating ERs by 5%), that assumption would be bass-ackwards as well. Quite the opposite; we're the victims of our own success, and quite literally drowning in business.

Oh yeah, and ACEP is based in Dallas, not Washington, asshat.

It goes on:

According to ACEP, hospital emergency rooms across the country are being flooded with patients who have lost their jobs and health insurance and have “suffered medical emergencies as a result.”

Yes. And, according to ACEP, water is wet and the sky is blue. The implication is not accurate that the current economic crisis is causing the crisis in emergency medicine. It's too soon for the 3 million newly unemployed of 2009 to have had much impact on ERs. There are many contributing factors to the ER overcrowding crisis: the uninsured are only one part. There's the slow death of primary care, the practice of boarding admitted patients in the ER, the closure of many acute care hospitals, and the growing and aging population of the United States, all combining to overburden a strained safety net. The fundamental truth of the claim is undeniable: if emergency care was "at the breaking point" in 2006, the economic crisis is predictably going to make things worse.

At the same time, according to ACEP, hospitals are reducing their ER capacity through tougher treatment policies to reduce their operating costs. Mix the two forces together and you have a catastrophe waiting to happen, ACEP says. And it’s a catastrophe that only the federal government can solve with legislation.

Well, that's just bullshit - a complete and utter distortion of ACEP's positions. Yes, many ERs have closed -- actually, it's more that the hospitals that used to host ERs have closed. But most hospitals are scrambling to increase capacity (with limited results) in order to better handle the deluge of patients. Perhaps the "tougher treatment policies" line is a reference to the University of Chicago situation, but this is not a wide-spread practice, and in fact, were it true, would support the contention that the nation's ERs are overwhelmed. I'm not sure which orifice he pulled the "only the federal government" bit out of, because the fix for the overcrowding problems goes well beyond a legislative patch. Did he even read the bill? It's as if he thinks the act is a sweeping reform bill, rather than a call for standards, a commission, and some extra funds. It's a small step towards fixing a very big problem that will require many stakeholders' participation.

Moving on:

Here’s where things get a little fuzzy in terms of verifiable information on which to support the legislation. How does ACEP know that hospital ERs are seeing more patients who have lost their jobs? That conclusion comes from a survey of 1,734 ER doctors...

I agree that the survey was of limited value. I've been watching our payor mix carefully and have seen only a small uptick in the uninsured -- from 16% to 17.5%. But is Mr Burda stupid enough to suggest that this historic recession is not going to increase the number of the uninsured? Do we need proof of that?

The second part of ACEP’s argument is equally shaky. Based on a handful of stories in the media, ACEP says hospitals are diverting patients away from their ERs because, according to the hospitals, they’re not presenting true emergency medical conditions. In a news release criticizing an urban medical center for doing so, ACEP said, “If other community hospitals follow suit, it will be catastrophic for the growing ranks of the poor, uninsured and underinsured, especially during this financial crisis.” Again, the financial crisis is being used as a rhetorical hammer.

Again, the wrongness is obvious to a passing glance. It is not that "ACEP says hospitals are diverting patients" away -- there's no dispute as to the fact that ONE hospital IS doing so. There's no he-said, she-said to be had there. And ACEP strongly criticized this practice, citing data from the CDC that only 12% of ER patients are non-urgent.

For as long as anyone on our veteran editorial staff can remember, hospitals and ER doctors alike have criticized patients for using ERs as outpatient clinics to address nonemergent medical conditions. They blame ER overcrowding on patients who should be seen at their doctor’s office.

No, you are the one making that error, or projecting it onto us. Yes, it would help if those ten percent of patients went to a more appropriate avenue of care. But it would help a ton more if ER beds had increased to keep pace with the growing and aging population, and if my ER wasn't choked with patients who should have gone upstairs 24 hours ago.

And hospitals, physicians and other emergency caregivers have been encouraged to come up with solutions to unclog ERs by diverting patients to the most appropriate and more cost-effective settings for care. That philosophy gave rise to urgent-care centers and, more recently, the boom in retail clinics. Leave the emergency rooms open for patients with true medical emergencies. For anyone with a real emergency, that’s great. But now, ACEP says that’s bad. It says hospitals are going too far and patients with emergency medical conditions are being shunted away to other facilities.

Yes, because it has happened and because there are policies in place which make it inevitable that it will happen again.

So what’s ACEP really concerned about? It’s money. If hospitals are reducing the physical capacity of their ERs or limiting care to truly emergency treatment, it could mean less work for ER physicians.

I wish I knew what bizarro world he's inhabiting. As I said before, we don't have enough people to do all the work we have now. We'd gladly offload some of it if we could -- but not at the expense of patient care.

In ACEP’s news release announcing its support of the bill, it says the legislation recognizes “the need for additional resources in support of care delivery.” What does that mean? The translation can be found in the actual legislation. A provision in the bill would mandate a 10% increase in Medicare and Medicaid payments to ER docs.

He's half right -- there would be an additional payment for all physicians providing EMTALA-mandated care. (How odd -- did you notice that the unfunded EMTALA obligation is completely absent from his article?) This payment would be directed to any physician, not just the ER doc, who provides uncompensated care in the ER. This is a critical measure in reinforcing hospitals' on-call specialty rosters. Specialists don't like to take call for the uninsured patients that come in through the ER, so they often drop out of the ER call rotation, or demand compensation from the hospital in return for taking call. Under this act, there would be an incentive for specialists to remain available for ER duty. ER docs would disproportionately benefit from this section, but then, we've been taking care of the uninsured in a disproportionate fashion for twenty years now, so that hardly seems unfair.

That’s what makes this piece of special-interest legislation so distasteful. ACEP is stepping on the backs of the sickest and most-injured patients to reach for its government handout.

How are we "stepping on" their backs? In what way does strengthening the safety net and providing a small offset for uncompensated care harm patients? How can any un-biased person suggest imply that improving the availability of on-call physicians is a bad thing?

A better question: Who is this clown, and why does anybody let him out in public, let alone write for a healthcare publication?

03 March 2009

Talking Economics - A Guide

Yeah, this is pretty much my M.O.:

Via the always brilliant Saturday Morning Breakfast Cereal. Click through to see the rest -- it's worth it!

Winner -- most depressing iPhone App!

Via MacWorld:

Few headlines are as depressing as those announcing the yet another round of layoffs from yet another struggling company. On Friday, February 27, for example, Pilgrim’s Pride announced it would close three chicken-processing plants, shedding 3,000 jobs.  In all, I read about 22 companies or government agencies planning to shed employees through Santhi Rudraraju’s Layoff & Hiring News—007 app for the iPhone.   Layoff’s simple but drab interface befits these austere times.

This one must have been a joy to code.

The Fairness Doctrine, Movin' Meat Edition

In which I cite an organization I generally disagree with.   The conservative American Enterprise Institute has a fact sheet about the uninsured.   It's actually pretty good stuff, and fairly accurate, without significant discernible bias.   I might disagree with the summary a bit, and some of the spin, but the body of the work passes my sniff test.   Kudos to them.

Interesting tidbit:

Q. Do many higher income people choose to be uninsured, even though they could afford to buy coverage?
A. Surveys suggest that one of the more significant sources for recent annual increases in the number of uninsured Americans involves persons in relatively higher income households. According to the CPS, more than 17.6 million uninsured live in households earning more than $50,000 a year, and household income is above $75,000 for more than 9 million uninsured. However, those numbers overstate the actual income available to those uninsured individuals, because household units are defined more broadly than are insurance purchasing units. As the composition of “households” changes, their income isn’t the same as family income available for spending on health insurance. The rising cost of coverage remains the primary barrier to insurance coverage for the uninsured, and in some cases, its value just may not be “worth it” for those in higher income families. But a more narrow and consistent measure of the higher income uninsured is closer to 2 million, involving people with regular incomes over $50,000 who lack insurance for spells of more than a year.

The author does not show his work in paring that 17 million down to 2 million, but the rest of this seems spot on.  Note that "the rising cost of coverage remains the primary barrier," which argues against the commonly cited belief that higher-income people simply "choose" not to purchase insurance.  I also like this graph, which I have seen before from NCHS:

Your Official Scary Graph of the Day

Here's your Official Scary Graph of the Day:

Oh boy.

And a little armchair economist on my part:
According to Atrios/CNBC, the european banks have an aggregate $24 Trillion of "toxic assets" on their books.   Yikes.   Fareed Zakaria wrote a couple weeks back that the European banks have tended to leverage themselves at much higher rates than US or canadian banks: Canadian banks are typically leveraged at 18 to 1—compared with U.S. banks at 26 to 1 and European banks at a frightening 61 to 1.   No wonder they were able to accumulate such levels of toxic assets.   I lost the original cite, but I read somewhere else that AIG's London office was primarily responsible for the worldwide Credit Default Swap crisis.

My point here is that it's been the common tendency to view the looming depression as an American problem, fueled by the American housing bubble and banking practices.   Perhaps that is still true.   But it appears that there may be much more of a European component than previously recognized.

02 March 2009

Scaremongering

And so it begins, in earnest.   A few weeks ago, it was Betsy McCaughey's op-ed, falsely claiming that the NCHIT office would force doctors to provide only approved medical care, that got wide play in the zombie right-wing press.   Today, there is this headline in the Boston Globe:

US system to rate health therapies
Critics fear plan may lead to rationing

I have to concede that this headline is perfectly accurate, though I would say that the conservative opponents of health care reform are afraid of so many things that the sub-title could as accurately read, "Critics fear plan may lead to single payer," or "Critics fear plan may lead to socialized medicine," or "Critics fear plan may lead to the END of AMERICA as we KNOW IT!"  So I would take the bogeymen of the right wing with the proverbial grain of salt.

What they are raving about is "Comparative effectiveness research," or CER, in which various therapies are compared against one another to see which works better.   It sounds simple and inoffensive enough, doesn't it?  Isn't that the whole point of science and evidence-based medicine -- to conduct experiments and use them to guide medical decision-making?

Yes, but, if you are an lobby with an interest to defend, say you make a large number of expensive drugs or implantable devices which may or may not be more effective than pre-existing, cheaper products, you have a powerful interest in protecting your bottom line by blocking or discrediting CER.   And if you are a political opportunist opposed to Obama's health care reforms for ideological reasons, then this is an easy chance to frighten away support for reform by screaming "rationing!"

Just for the record, if, as the sober-eyed "health economist for the conservative Heritage Foundation" gravely warns, this does result in "restricting treatment options based on a government-run board's interpretations of research," it is important to understand: that is not what rationing is.

Rationing is generally understood to mean the practice of restricting allotments of resources due to scarcity.   As applied to health care, this generally means that certain therapies are not covered, or that only a fixed number of persons are allowed to get them.   Think of waiting lines for knee replacements, or managed care plans who refused to cover bone marrow transplants for breast cancer (which, ironically, were not effective any way).   That's rationing.

It is something of a sad statement on the bizarre poltical world we are about to enter that people can posit things such as "care that is not deemed most effective should be covered" and "research should not determine whether procedures or drugs will be paid for" and still be taken as serious, rational, good-faith participants in the debate.   Of course if there are therapies which are ineffective, we should stop paying for them!  Of course if there are comparably effective therapies, the cheaper one should be favored!  Anybody who cannot agree with simple principles like these is either stupid or corrupt.

My point, however, is that, if this came to pass, if there were some "government board" arbitrating the efficacy of competing therapies based on CER (which there is not, and no proposal to create), that is still not rationing!   It is evidence-based medicine, writ large across a health system.

A health system, I hasten to add, that is consuming 17% of the GDP, and increasing in size year after year.

So it would not necessarily be a bad thing, implemented properly, to have guidelines based on good research showing clearly which treatments work better, and are cheaper.   And I will agree in advance with the inevitable commenters that a restrictive, inflexible, heavy-handed managed care approach to cutting off less-effective or more-expensive treatments would be a bad thing.  But I can imagine market-driven incentives, as outlined in the linked article, that might work well, such as " a tiered system that requires patients to pay more for treatments that are seen as less cost-effective."  Imagine that -- care which is more effective, and costs less.

I get email

(With apologies to PZ Myers)

Tucson, AZ (March 2, 2009) - A new petition calling for revolutionary health care reforms and health freedoms was launched today at http://www.healthrevolutionpetition.org/

The petition -- which is endorsed by NaturalNews, the Organic Consumers Association, the Life Extension Foundation, the American Association for Health Freedom and other health freedom groups -- calls for an end to FDA and FTC oppression of free speech about dietary supplements. Its ten provisions also call for full income tax deductions on health-enhancing products and services, a halt to the psychiatric drugging of children, the end of mandatory vaccination policies and the legalization of healing practices across the country. (The carrying out of natural anti-cancer therapies, for example, is currently outlawed in the United States.)

It goes on for quite a while, but you get the gist, I think.   

Just for reference, no, I will not sign this petition for woo, quackery, and anti-vaxxers.   But thanks for asking, and please take me the heck off your distribution list.   Ah, never mind, that's what spam filters are for.

Oh, one closing gem:

The petition aims to gather 100,000 signatures in 2009, after which it will be distributed to each member of Congress as well as President Obama and his staff. A special, signed printout of the petition is being delivered to the office of Rep. Ron Paul, who has consistently served as a champion of health freedom for many years.

Yeah, it would make sense that this would be specially delivered to Ron Paul.   Gad, he's a nut in each and every opinion he holds, isn't he?   If nothing else, I've got to admire his consistency.

01 March 2009

Once in a Lifetime

G'night.

I missed that angle

The insightful Joe Paduda at Managed Care Matters notes one interesting thing about the Obama health care framework proposed last week:

There's something for everybody to hate, as everybody is required to "give" something, except for physicians.

Weird, when you think about it:

• Higher premiums for affluent seniors;
• Hospitals see reduced payments for bounce-backs;
• Insurers kiss good-bye to Medicare Advantage;
• Drug makers must increase the rebates on medicaid prescriptions.

But no hit to physician compensation.

In fact, when you look at the rest of the budget, the honesty in reporting guidelines he has adopted assume that Medicare Part B compensation to physicians will remain steady, instead of assuming the huge reductions that the Bush budgets did under the SGR formula. Though that's up to Congress to implement, it reflects the implicit assumption that physician compensation under medicare should not be further reduced. Or at least the political realities argue against it actually coming to pass.

Joe wonders whether this is a chess stratagem where Obama is trying to set up a "Doctors vs everyone else" situation by leaving physician funding intact. I doubt it -- it's too devious, and he's been pretty forthright in the painful compromises he's set forth. I suspect that rather than invoke the opposition of the doctor's lobby straight out, he has chosen to let Congress do the dirty work (if it is to be done) and "gore our ox" when the plan is somewhat further along. Given that only about two-thirds of the funding for universal health has been identified, it's hard to image this plan playing out without physicians being asked to give as well.

By the way, I think "gore our ox," sounds like an extremely perverse euphemism, though I'm not quite certain what for.

While the details are too sparse to make any predictions, EM is in an uncommonly sheltered position. Consider a hypothetical practice which sees 20% uninsured patients and collects about the medicare rate per RVU billed -- say $136/patient on 3.5 RVU/pt. (Remember this is actually collecting $170/pt on the funded patients and $0 on the uninsured.) Let's assume that a truly universal plan is enacted, and the 20% uninsured are equally split between medicaid and commercial insurance. For the sake of simplicity, that averages out in our state to be about the same as the medicare rate. So now that same practice will be seeing collections of $164/pt in this new reimbursement environment -- a 20% increase! Now the numbers in this example are pure fiction, but it doesn't matter -- the proportionate increase in collections should track closely to the fraction of a practice's patients which were uninsured, assuming the newly insured more or less match the existing blended payer mix. More lucrative practices with fewer uninsured and exceptional payer mixes will see much more modest revenue increases; practices with large numbers of uninsured will be very positively affected.

The same calculation would apply to any specialty practice, but due to the higher fraction of uninsured patients seen in the typical ER, the revenue side of universal health care brings an inherent positive for EM. If, as I suspect, the government asks doctors to "give" a bit, we will be buffered on the give-back, and stand a reasonable chance of coming out ahead or at the least even.

The other question I have is, if the negotiations involve some physician concession, how that might be accomplished. Medicare could do it with an across-the-board devaluation of CPT RVU codes, assuming that private payers would follow, but that is a very blunt instrument and would fall unequally across different specialties. Perhaps the assumption is that this would be part of a physician fee schedule restructuring to further swing the pendulum from proceduralists to cognitive specialists and primary care.

I don't know. I assume that the doctors are just too fat a target for the legislators not to go to the well, and it will come eventually. But for the moment, it's nice to see the basic framework developed in a way that has no direct negatives for practicing physicians.

Inside the mind of a magician

A very cool profile of Teller, of Penn & Teller.

It is impossible that this story be about anything other than a 3 ½-minute trick in the Penn & Teller show. It is a very beautiful trick that can’t be fully conveyed with words because it looks so simple: Teller makes a ball come to life. It isn’t a very exciting trick in that no knives, fire or risk are involved. A lot of their tricks have those.

And, to make matters worse, the trick I have the (partial) lowdown on, Penn doesn’t particularly like, or at least not until after he tells the audience how it is done—with a thread—before he walks off stage. And, therefore, yes, that’s right: This is going to be a story about a ball and a string—and Teller.

After Penn walks offstage, Teller, hoop in hand, slowly coaxes the ball to life and makes it do his bidding. Over the course of the trick the ball goes from indifferent to awakening to willing playmate. Though the narrative has Teller getting the ball to jump through his hoop, the ball’s most singularly beautiful moment is when it attains a perfect balance on the edge of the hoop.

Just for the record

George Will is, and always has been, full of shit.

What is a weekend?

To an ER doc, it's just a day when the kids don't go to school,
When the commute in to work is less busy than usual,
When the mornings are quiet, and the evenings crazier than usual,
When the clinics are closed, and non-acute patients crowd the waiting room,
When everybody else is out doing stuff with their families,
When the drunks roll in earlier and in greater numbers,
When Interventional Radiology has no scheduled cases,
When primary care docs are beyond all reach, and follow-up impossible to coordinate,
And when the lines at the ski lifts are longest.

But I'll be off on Tuesday!

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