Blue Angels

It's hard to take a bad picture of the Blue Angels, but it's also hard to take a good one. It's surprisingly easy to take 144 pictures that all look more or less the same. (Click pictures to embiggen.)

These are the best that I got today (link to gallery) watching the Blue Angels "practice" over Lake Washington. It's not really a practice -- it's a full show, but tomorrow's the Big Day when Seafair is going on. It'll be so busy that I couldn't stand to be anywhere in the vicinity, but today was lovely -- had a little picnic in a beach park over on the Eastside, the boys played in the water, not too crowded. It was just perfect.


This is why I love digital pictures, not that anyone needs to hype digital over film any more. But in the old days, 144 pics would be about 4 rolls of film, which cost a fair amount of money and also cost a fair amount to develop & print. And if you used a commercial printer, the end result didn't look particularly good. If you wanted nice prints you had to develop them yourself -- which I learned to do. It was fun and creative but very labor intensive. With digital, the images are free (excepting the cost of disk space, which gets cheaper every day) and within an hour of getting home, I'd gone through them all, color-corrected, cropped and tweaked every image with any promise. Apple's iPhoto makes that brain-dead easy. If you want to do serious imagework you still need Photoshop, but for simple stuff iPhoto is easier and more than adequate.

On a more technical note, if you look carefully at the above photo you can see that they are using two #7 aircraft (the two trailing planes in the #3 and #4 positions). You can see, faintly, the "7" on the vertical stabilizers and they have larger canopies as these are the two-seat versions of the F/A-18, which are not typically used in shows. Last year's show was noteworthy, since the #6 plane had a mechanical problem after takeoff and had to turn back and quickly switch to the #7 plane. I don't think they allow ridealongs during the show, since they pull something like seven g's without pressure suits! Perhaps they just have two aircraft with mechanical problems...

Interesting.

The Big Picture Never Disappoints

Cool photo-essay of lightning around the world:

Tops!

Is that the weather or a fever?



Damn it's hot.

Yesterday was the hottest day in Seattle, EVER.  Not the hottest July 29th. Hottest ever.

And we were outside all day at kids' soccer camp. Gah.

Snap, Crackle, Pop

Pharyngula has a great post -- a reprint of the Simon Singh article that got him in so much trouble for exposing chiropractic quackery.  One point worth emphasizing: chiropractic manipulation is not necessarily benign.  Chiropractic stuff is very popular where I live, and in my relatively short career I have seen not one but two vertebral artery dissections and cerebellar strokes that were attributable to chiropractors.  A bigger problem, I think, is that while there are good chiropractors who understand their optimum scope of practice, there are a damned lot of crazy quacks out there.

I have something of a confession: I once visited a chiropractor.  This was quite a while ago; I was playing with first-born son, who was about 18 months old and I had one of those "ouch" moments where my back just went out.  I could not straighten up.  I could tell the pain wasn't radicular.  It didn't feel myofascial either.  Eventually I managed to get vertical, and it was more or less painless unless I bent forward more than about 30 degrees, at which point developed sharp and localized pain and couldn't go any more.  It felt like it just needed to pop.  After a couple of days of it not getting better, I decided to see if a little back-cracking might do the trick.  So I went down to the chiropractor a few blocks from my house.

I didn't tell him what I did for a living.  He asked me what the problem was, and I got about thirty seconds into the story before he cut me off with a question.  That didn't surprise me; doctors are well-known to do that.  But the question surprised me: "When was the last time you had your back x-rayed?"
"Um, never."
"Ohhhhh!" He interjected, with good humor and a touch of bonhomie, "Thought you were gonna get away with something, eh?  Thought you could pull a fast one on me?"
"Um no, but..."
"To the x-ray machine we go!"  And he bustled out of the room, indicating that I should follow.  What the heck, I figured, I'm already down the rabbit hole, let's play the game and see where it goes.  So I followed.  We took an x-ray and I waited in the room until he came back. 

"Looking at your x-ray, you have two problems.  Some degenerative changes in your lumbar spine, and your pelvis is tilted."
I was kind of shocked.  DJD?  At my age?  I was, I think, 32 years old.  Too young for DJD.  "Can I see the x-ray?"
"Oh well, you honestly don't need to..."
"No," I interrupted quite firmly, "I would really like to see the x-ray."
He led me into the next room, muttering something about having trouble with the developer, and showed me the faintest, least diagnostic x-ray I have ever seen in my life.  I examined it closely.  The "degenerative changes" were clearly a figment of his imagination.  He eagerly pointed out to me that the pelvis was "tilted" or, as I would say, rotated.  It was, slightly.  He explained how this meant some malalignment or another.  I pointed out that I just wasn't quite square with the plate when the film was shot.  He assured me that he had made certain that I was square (which I do not think he did).

Either way, he told me, it was clear that I needed some manipulations.  Again, I was shocked.  He had not asked me any questions.  He had not examined me.  He had no idea whether I had symptoms suggestive of nerve pain, or spinal cord injury, or any concept of what the cause of my symptoms might be.  I considered yelling at him, or walking out.  But again, I figured, I wanted some back-cracking, I'll let him give it a go and see if it helps.  I lay on the table and pop-pop-pop, up my lumbar and thoracic spine he went.

And I felt better.

I never went back to him.  The symptoms were resolved, and he was clearly a dangerous quack.  But for my minor problem, on a pragmatic basis, I was prepared to accept that the adjustments had worked.

I should point out that a year or so later, my problem recurred.  I went to see a different chiropractor.  This one was quite different.  He took a careful history and performed as thorough an exam as I would have expected from a physical therapist or physiatrist.  He explained that he thought it was a muscle strain and that I did not need manipulation, I needed stretching exercises, and he gave me a list of some fairly standard exercises.  I came away from that encounter with a solid feeling of respect.

I would not impugn the profession by saying they are all quacks.  The second guy was clearly good and responsible.  I have a sketchy feeling, however, that the first chiropractor may be more characteristic of the norm.  Because it is popular in the neighborhood I live in, many times I have patients ask me whether they think they should see a chiropractor for their problems.  I generally dissuade them, of course.  I refer them to their docs and a physical therapist.  But some folks clearly are bound and determined to see a chiropractor.  That's tough, but I reinforce to them that they should not let the chiropractor touch their neck, and that for most of what I see, the stretching and muscle strengthening exercises are also important.

And just for the record, any chiropractor who thinks that manipulations can improve colic, or ear infections, or asthma is either lying or deluded.

Read About It

Classic Oil

Breaking: House Dems reach deal on health insurance reform

House Retains Public Option In Compromise, But Delays Vote Until September | TPMDC

There will almost certainly be a bill ready for a vote when the House comes back into session in September. That bill will have been endorsed in preliminary votes by a significant number of Blue Dogs. And in the House, where there's no filibuster, that makes its prospects for ultimate passage look very solid.

Conservative House Dems, known as "Blue Dogs" had been balking at the more liberal version of reform that the Tri-Com panel had proposed with HR 3200.  There had even been a total breakdown of discussions between the Blue Dogs and Energy Chairman Henry Waxman last week, with Waxman threatening to bring the bill straight to the floor, bypassing his own committee.  Things were looking pretty bleak in the House for a while.

Aparently now the intra-party disputes have been settled, to some degree, and the details of the compromise are beginning to emerge:

• The Public Plan is retained, but slightly weakened.
• Rates for the public plan are no longer based on Medicare, but must be negotiated separately by HHS.
• States may start health care co-ops in addition to the public plan, if they choose.
• Employers must still offer health insurance or pay a penalty.
• The exemption for small businesses has been doubled from businesses with payrolls <$250K to those with businesses <$500K.
• The subsidies for higher-earning people will be slightly reduced.

Ostensibly, this version of the bill will cost about $100 billion less.

As mistrustful of the Blue Dogs as I am, if this report is accurate, it may be that this is actually an improvement on the original proposal.  I've never been a proponent of a too-strong public plan, and even as a bleeding heart lib, I can tolerate reduced subsidies for folks making, what $66-88K per year? 

More important is what this compromise preserves:

• The National Insurance Exchange
• Community Rating
• Guaranteed Issue
• Individual Mandates
• Employer Mandates
• Universal (or near-universal) coverage

Thus, the heart of the reforms are intact.   I was getting a little worried: if the House couldn't get anything done, what hope was there that the Senate would ever be able to get on board?  The big concession the Blue Dogs seem to have extracted is that there won't be a vote of the House till September.  That's just Politics 101: don't make your vulnerable members stick their necks out on a tough vote until it looks like the Senate is in sync and the whole thing is moving forward.  Otherwise, if the House passes something now, and the whole thing dies in the Senate over the recess, then a whole slew of Democratic representatives will be in the worst of all worlds: having taken a hige risk voting for a controversial bill that doesn't even pass.

Hopefully that eventuality won't come to pass, making these fears of the Blue Dogs moot.

How to Make Money in Primary Care

Cleveland Doc, a surgeon at the Cleveland Clinic, commented on my salary post from yesterday, that there are, as I suspected, productivity-based components in the much-vaunted "salary" models that the Clinic employs.

Cleveland Doc also reminded me of something that may be common to large practices.  The Cleveland Clinic sounds like a large multi-specialty clinic in our town.  The "Big Clinic" has hundreds of docs of all stripes and is nationally recognized as a leader in quality of care and is a model for CMS in their efforts to create the medical home.  Good place, and a lot of good docs.  A couple of years ago, one of our ER docs went to work in one of their urgent cares.  I was astonished at how well they were able to pay him.  Not as well as ER, but way above the national average for primary care.  Apparently their internists do even better.  No way they were able to justify this compensation purely on the pro fees they were generating.

I did a little discreet inquiring into their business model that allowed this level of remuneration.   It seems that large practices like these can view primary care as a sort of "loss leader."

In classical marketing, a merchant may offer a common product at a loss: say, your grocery store may sell milk for less than the wholesale cost of a gallon.  They do this because they know that when you run in "just" for a gallon of milk, you are also likely to make another purchase of something with a higher margin.  So they get you in with the milk knowing that they will make a profit off of the ground beef and candy bars you pick up while you're there.

Similarly, the Big Clinic can afford to "sell" you the product of primary care for less than their actual internal costs of employing that doc.  Because they know that those primary care docs will refer patients to their specialists, and their CT scanners, and their MRIs and their outpatient surgical center, and their lab, etc etc etc.   All of these are profit centers.  So some of the margin generated by these "ancillary" sevices goes back to the primary care providers.

This is a good way to run a business, since the Big Clinic can pay PCPs well and recruit good docs thereby creating a good feeder stream of patients to the profitable elements of their business.  It's also a good way to deliver care.  The system is integrated, facilitating communcation betwixt the specialties.  And it compensates for the failures of the RVU system; the surgeons at the Big Clinic make a little less than they might in private practice, but the primary care docs are not being starved to death by shrinking reimbursement.  In fact, I don't even know that the surgeons make less - it may be that the imaging and surgical centers allow everybody to make more! 

The hardest thing for some to swallow, though, is the loss of independence and autonomy that physicians have so fiercely fought to preserve, historically.  Some docs hate being an employee and can't stand being subject to QA and audits and performance reviews, no matter how much they are making.  They tend to either flame out or self-select back into solo practice.

Barring a fundamental change in the RVRBS, this model may be the future of urban medicine in the US.

Deep thought

If:
You have recently suffered a major stroke which has left you with impaired mobility.

And If:
You have severe arthritis and needed to use a cane to get around even before your stroke.

And If:
You have drunk "a lot" of beer to celebrate being released from jail today.

Then:
You should not be diving into the swimming pool

Corollary:
In any event, you should not be diving into the shallow end.

Please make a note of it.

It must be linked

William Shatner's recitation of Palin's farewell address.

Also, Conan O'Brien is like seven feet tall.

Cognitive Dissonance

It was a busy, busy Monday evening in the ER, about nine PM.  A mother brought her 18-month-old daughter in for some remarkably trivial cold symptoms.  Despite the onslaught of patients, I actually got in to see her pretty quickly.  I glanced at her demographic page in the chart as I bustled in.  Hmm. Good insurance, has a well-respected local pediatrician: odd.  Not your usual fare for a totally non-emergent complaint.  More typically it's someone with no insurance who can't get in to see a PCP, or their PCP is at the Community Health Clinic which means that they essentially don't have a PCP*.  I wonder why they're here?

So I interview the mom and examine the kid.  Runny nose, mild cough, a little sneezy, red eyes that really aren't red on exam. No fever, even.

Afterwards, I'm chatting with the mom, I explain that the symptoms look pretty benign, and I ask her, "So when you called Dr Jones, did he tell you to come to the ER?"
"No, we didn't call.  His office was closed."
"Did you call the on-call number?  They always have a nurse and a doctor available for after-hours problems."
"Oh, no!  We didn't call that number -- it's only for emergencies!"
[long pause]
"And yet, here you are now.  In the Emergency Room."

She had the decency to flush a bit.

I sent them on their way with general instructions for a cold (no antibiotics!) and instructions to call their doctor for follow-up. 

She's gonna be so pissed when she gets the bill.  It'll be their $1800 cold.



* No offense to the CHC folks.  They do great with very limited resources.  But they are so overwhelmed that there is no capability to see acutely ill patients.  When I see a CHC patient in the ER for a non-emergent complaint, I don't give them a hard time, because I know that the clinic's next appointment is in October or so...

I still remember

Nathan:



I'll be thinking of all of you today, as I do every day.

Journamalism, the finale

In which I conclude my interview with Dr Jouriles, the President of ACEP.  Fair warning: we conclude with an extended free-verse poetry slam, so if that's not your sort of thing you may want to stay away...

Dumbest Arguments against health care reform

From TAPPED:
The 10 Dumbest Arguments Against Health-Care Reform | The American Prospect

What we really need is a "bipartisan" health-reform bill -- and if Democrats act properly, they could get one. The myth that "bipartisan" legislation works better than partisan legislation is widespread, but virtually no real evidence supports it. For every successful program passed with support from both parties, you can find another one that failed. There are also plenty of popular programs that enjoyed the support of only one side. Republicans aren't afraid to attack Medicare because some party members voted for it in 1965; they're afraid to attack Medicare because it has been hugely successful at achieving its goal of providing quality, affordable health care to seniors. The future popularity of the current health-care reform will be a function of whether the program works, not how many Republicans voted for it.

More important, Republicans are not going to vote for this health-care reform, no matter what the final bill looks like. Chances are it will get zero Republican votes in the House and maybe two Republican votes in the Senate, tops. Anyone who thinks more optimistically has been partaking of too many free samples from pharmaceutical lobbyists.

This one was my favorite, but they're all pretty good.

What GruntDoc Said

GruntDoc » Blog Archive » Salaried docs vs. fee for service

What salaries do not do is get docs to work harder, see more patients. Some docs are very dedicated, motivated people who would work for rent and grocery money. Others on a salary would do the minimum: if every patient is more work and more liability without more pay, well, why work more/harder? As an incentive to produce nothing beats getting paid for it.

Also, a happy side effect of getting paid for what you do rather than for having a pulse is those who work hard resent those that don’t (but who would make the same on salary) a whole lot less. Way less inter-group stress.

Salaries aren’t all bad, but they’re not the Key to Great Healthcare.

Ditto.

I've been in a salaried model, and it was painful.  There'd be three docs on duty and the call from the medics would come in that there was an intubated drunk trauma or the like, and I'd look up and find that my two partners had managed to slip off to the cafeteria.  We switched to a (modified) fee for service, and suddenly, docs were eager to care for patients.  Each new ambulance that rolled in represented an opportunity, not a burden.  Why does this matter?  Because the waiting room was always full.  Patients were languishing hours before being seen by a doc.  And our salaries were low enough that we couldn't easily just hire/staff more doctors.

Now, our docs are on average 20% more productive and the average patient is seen within thirty minutes of arrival.  Productivity pay was not the only thing that enabled this, but it was huge.

The ironclad rule of management is this: You get the behaviors you incentivize.

I can see the policy-level benefits of eliminating the fee-for-service incentives to over-utilize.  But it's a complex system with many moving parts, and without motivated docs, the system bogs down.

The Cleveland Clinic and Mayo are oft-cited as awesome because of their salaries; I'd be really interested to get the details of that salary model and I wonder if we'd find that there are some incentives buried in there.

From the Journal of the Intuitively Obvious

Driven to Distraction - Texting Raises Crash Risk 23 Times, Study Finds - Series - NYTimes.com

when the drivers texted, their collision risk was 23 times greater than when not texting.

This is a pretty crude metric of risk, by the way.  Sure, 23 Times the risk makes a great headline, doesn't it?  And it serves the public health interests of providing dramatic evidence that it's not a good idea to drive & text.  Of course, those who need to be convinced are the least likely to read this article & care -- this sort of research seems instead tailor-made to support legislation in various state houses prohibiting DWT (driving while texting).

Still, I'd be happier if they gave you raw accident risk rates rather than relative rates.  Is it 2.3 accidents per 10,000 miles driven?  2.3 accidents per 100,000 miles driven?  And this "23 times" figure -- is it just for the time period that the drive is texting, or is it a global figure comparing the accident rates of drivers who text to those who do not text?

By the way, when I swapped out my blackberry for the Holy iPhone a couple years ago, the biggest irritation was that since I had to look at the screen to type, I could no longer text while driving.  With the blackberry, I could type accurately without taking my eyes off the road.  Probably for the better, eh?

More Journamalism

Part Two of my interview with ACEP President Nick Jouriles is up over at The Central Line.  We get a little more into policy issues and the politics of health care reform.

SPOILER ALERT: He thinks the ER is the central part of the health care safety net!

Propofol and Wacko Jacko

Kevin has more on the reports that Jackson may have died from a propofol ... well, I was going to say "overdose" but that's not quite right.  Jackson may have died from the predictable effects of using propofol outside of a carefully monitored medical suite:

Did Michael Jackson’s doctor give propofol, a possible cause of death for the King of Pop? | KevinMD.com

According to ABCNews, “the autopsy of Michael Jackson found the powerful anesthetic propofol, as well as several prescription drugs, in his system, and law enforcement sources say that investigators believe their final report will list the propofol as a ‘contributing factor’ in his death.”

Wow. Just wow.

For those of you who may not be doctors, this is something just shy of "unbelievable."  Propofol is an awesome drug for procedural sedation, but it's got to be used with real respect.  It's most typically used as an induction agent for general anesthesia by anesthesiologists in the operating room. At our hospitals we use it for moderate and deep sedation for painful procedures in the ER.  We had to go through quite a fight to get it, too.  The anesthesia service blocked us for years, contending that this medication is terribly dangerous and that ER docs lack the necessary training to safely use this drug.  ER docs -- the ones who intubate and sedate patients every single day of our working life!

Truth be told, they had a point.  Not about our skill set, of which they were totally ignorant. But about propofol.  It's dangerous if not used carefully.  A little too much (or a patient a little too sensitive) and you have a patient who is not breathing any more.  If you don't carefully monitor the patient's respirations you may not even notice that they are no longer breathing.  Since there is no reversal agent, if you put them too deep you had damned well be ready to manage their airway, or at a bare minimum provide some rescue breaths with a bag-mask device.

So we use it, but only in a selected subset of patients (ASA Class I and II) and in carefully controled environments and with extreme caution.

Part of that caution is due to the fact that people are really unpredictable as to their dosing requirements.  A "standard" dose might be 1 mg/kg, or about 70 mg for a typical adult.  But some folks are snoring (a sign of possible airway compromise) at 30 mg, and I've seen children use a whole bottle (200 mg or about 8 mg/kg) and still scream and thrash their whole way through the procedure.  There's no way to predict reliably, so you give it carefully and slowly and monitor the patient's response.

So the suggestion that some dipshit "cardiologist," who was according to reports not certified by the ACC, thought it was a good idea to give propofol to an unmonitored patient in an out-of-hospital setting for no possible justifiable purpose just blows my mind.  Bear in mind that this drug is the one that is so dangerous that anesthesia thinks ER docs are too dumb to use.  And he thought that a private home was an appropriate venue for its use.

If it's true, there have got to be consequences for the physician. In the medical world, you tend to think of consequences being malpractice or losing one's job -- not severe enough.   Losing his license?  Closer, but still not severe enough.  He should go to jail for manslaughter.   Seriously.  If it's true, Dr Murray killed Michael Jackson as surely as if he'd used a gun.  And the act of using propofol in a patient's home is reckless beyond any possibility of redemption.   It's willful and wanton negligence, and while I know jack squat about California law, there's got to be some sort of law regarding negligent homicide with real penalties.

Journamalism

In which I play reporter and interview ACEP President Dr. Nick Jouriles about health care reform. That guy can curse like a longshoreman!

Actually, he was very good.  I was impressed by his wonk-fu when it comes both to the nerdery of health care policy and the ability to understand and navigate the political arena.

Part one of three is up now at The Central Line.

If anyone cares, I used a transcription service called We Scribe It to get the conversation typed out.  It was long; over fifteen pages unedited.  But the cost was tolerable, actually excellent for the amount of time it saved me.  I found out about them on Twitter of all places.  Who says Twitter is a colossal waste of time?  Well, I guess I do, but at least one productive thing has come of it.

Drawing a line

It was a busy Saturday afternoon today, and the charge nurse came by to let me know about a "heads-up" we got from the rehab center across the street.  The nurses there are pretty good about letting us know when one of their patients needs to come over, which is nice because their patients tend to be chronically ill and kind of complex (otherwise, they wouldn't be in an acute rehab center!).  This one was a little weird, though.

Says she: "The rehab nurse says they have a patient with an upper extremity DVT they are going to send over for evaluation."
I said: "That's odd, how do they know it's a DVT?"
"The patient already had an outpatient ultrasound."
"Oh." [pause to think] "It sounds like they've already got the diagnosis, don't they?"
"Yes."
"And they can give lovenox over at rehab, right?"
"Yes."
"So why are they sending the patient to us?"
"The patient's attending said to send him over."
"Why?"
"I have no idea."

So she calls back to rehab and verifies that we have the story straight.  We find out who the attending is, a Dr. Jones who I have not met before, and I have him paged.  This was an interesting chat, summarized so:

"So, Dr. Jones, I gather you wanted to send us Mr. Anderson for assessment.  I just wanted to touch base with you and get a sense of what it was you wanted us to do for him?"
"I don't know the patient; his doctor's off this weekend and I'm just covering.  The nurses say he has swelling of his arm, and they say there's a clot there, and I thought someone ought to take a look at it."
"OK, but if we know it's a clot, why don't you just anticoagulate him?"
"Well, the nurses said it's looking kind of red, and no physician has laid eyes on the patient. He really should be examined by a doctor before he's anticoagulated.  Don't you agree?"
"Riiiight.  Look, I'm not trying to make trouble, but the ER's really busy and the waiting room's full.  I'm not sure that this is an appropriate use of the ER.  This is something that his attending can look at and treat if it's appropriate."
"But he doesn't have an attending. His doctor is out of town."
"He does have a doctor.  That's you."
[long pause]
[the pause is now getting uncomfortably long]
[he still doesn't say anything]
"I'm letting you dangle."
"Yes.  I see your point."
"I'm not trying to be obstructive.  Ordinarily, I'd be happy to take $150 of the taxpayers' dollars..."
"No, no, you've made yourself clear.  I'll come in and take a look at him."
"Very well, and if you find something unexpected, by all means send him over and I'll eat humble pie."
"Right, thanks." [click]

I hung up the phone to a round of applause and a standing ovation from the nursing staff, who had been listening avidly to the conversation.  I actually felt kind of bad, that I was too tough on him, but the nurses really rallied around me.   One of the nurses said to me, "I can't believe you got Dr. Jones to come in!  He never comes in for anything!" 

I was just annoyed that it was clearly a dump on the ER for the doc's convenience.  This is the problem with the ER -- we're always there, and we're always open and we can't say "no."  When some doc in any outpatient setting doesn't want to deal with some problem, they can just turf it to the ER.  The doc was clearly astonished that he got pushback, that there was an expectation that he would have made some effort to see the patient he was covering for before sending him into me. 

This is to some degree an unintended consequence of EMTALA.  Because we cannot say "no" to transfers, the ER becomes the default option, and the path of least resistance.  We are the resource of last resort, and before long, that becomes the resource of first resort.  It's standard operating procedure to "just send it to the ER."  The only reason I had a chance to block it was because the nurses gave us the courtesy call in advance.  More often they don't call at all, or wait until the patient is en route before calling.  I didn't even "block" the patient, per se; it was only because I shamed him that the doc relented and took care of it himself.

The patient never did come in.  So I'll chalk it up as a victory, but I'm more sure it won't turn out to be a pyrrhic victory.   Next time, they just won't call, and it's gonna be way awkward the next time I have to talk to Dr Jones, especially if I need something from him.

Cakewrecks

Alert Reader "Blessed" pointed me to the wonderful blog "Cakewrecks" which documents "When Professional cakes go Horribly, Hilariously Wrong".

There was an ostensible medical angle, as the featured pics of the day were horrible baby shower cakes with 3-d ultrasound images screened onto them.   But nothing can really compare with the above sentiment, can it?  It's one of a multi-part sequence which should not be missed.

Bongi, once again

If you're not reading Bongi, you really should be.  For my money, he's the best storyteller in the medical blogosphere today.

The abuses of private insurers

This is a great example of the compelling need for regulation of the insurance industry, and for a public insurance choice for patients to prevent these sorts of abuses, if true:

Bayonne Hospital Center and Hospital Patient File Federal Lawsuit to Protect Bayonne, New Jersey Residents From Life-Threatening Business Practices of Horizon Blue Cross Blue Shield of NJ

Suit Charges Horizon with Systematic Attack on Emergency Care in Quest for Profit

BAYONNE, NJ, JULY 22, 2009—Bayonne Hospital Center (BHC)—the only hospital in the medically underserved working class community of Bayonne, NJ—today announced it has filed a federal lawsuit against Horizon Blue Cross Blue Shield of New Jersey (Horizon) [...]

Horizon’s practices and activities include, among other things: a systematic campaign of intimidating patients into abandoning emergency care at BHC that is already underway, including calls to patients and the sending of couriers to instruct patients to leave the hospital while still in the midst of emergency treatment; egregious and arbitrary denials of coverage and claims for emergency care at BHC; and constant efforts to under-compensate the only emergency care option in the Bayonne community, a hospital just rescued from bankruptcy.

The complaint filed today in the U.S. District Court in Newark, New Jersey provides a detailed account of Horizon’s business practices which run counter to the insurer’s contractual duties to its customers, its obligations under state law and its stated commitment to the interest of public health. Some of the most offensive Horizon practices detailed in the complaint include:

•A systematic campaign discouraging patients from seeking emergency care at BHC despite it being the closest and safest option for urgent care for the residents of Bayonne

•Intimidation of patients by threatening denial of coverage if they seek treatment at BHC

•Interference with care by sending couriers to BHC to tell patients undergoing medically necessary treatments to leave BHC and seek care at a hospital that is "in network"

•Indefensible denial of claims, often while the patient is still undergoing care

•Unilateral determinations by Horizon bureaucrats that emergency room patients are medically stable enough to be discharged to home or transferred to other in-network facilities without consulting the patient's attending physician

I've been in some epic battles with insurers, and I know that it can get ugly. But, wow. Sending couriers to instruct patients to leave? Forcing ER docs to discharge patients? That's way over any line I've ever heard of.

And yet Max Baucus and the Blue Dogs will fight tooth and nail to protect their buddies in the insurance industry.

I'm a sucker for slo-mo

Revenge from lernert Engelberts on Vimeo.

From Crazy Andy

A Timely Correction

Hysterical.  A correction published in the New York Times, July 17, 1969 (the day Apollo 11 launched):

(h/t regret the error)

Disclosure of Conflict of Interests

From the department of "Credit where it's due," in the comments of my post on the Lewin Group, Nurse K pointed out the following:

Come on Shadowfax, you're blogging about this stuff and you stand to make A TON of money if it goes through...for awhile...until insurance companies decrease your compensation since you're making more per patient. I know you mentioned this before in like a comment or something, but ER docs stand to benefit (temporarily) probably more than anyone else. HUGE bias on your part.

Much as I (really, really) hate to admit it, she's absolutely right.  In fact, I'll go one further: I first got interested in this part of medicine policy because I was mad that I was seeing all these uninsured patients and wasn't getting paid a thing for my efforts.  I started keeping track of the number of uninsured I saw every day, just as a pet obsession.  It was a sobering number.  After that I started getting a little perspective, talking to patients and seeing their bigger picture, understanding why they were uninsured, learning the particular challenges they faced getting health care, etc.   For me, this cause became something beyond the personal a long time ago and became a moral imperative. 

But K is right to note the potential for bias, and it's fair for me to acknowledge it.  I hope that my integrity on this point is evident.  The fact that I argued in the New York Times for an increase in primary care compensation, with an attendant decrease in the compensation of specialists, including Emergency Medicine, should speak well for my ability to see beyond personal self-interest. (God knows it didn't make me popular in EM circles!)

This is something which struck me yesterday, reading the med blogs reaction to Obama's presser.  Quite a few docs mounted their high horse and with great indignation denounced this:

Doctors are forced to make decisions based on a fee payment schedule that's out there. So they're looking... if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, "I'd make a lot more money if I took this kids tonsils out." Now that might be the right thing to do, but I'd rather have that doctor making those decisions based on whether you need your kids tonsils out...

Now it's a clumsy clinical scenario written by someone who has no clue about medicine.  But it's a damned fair point.   Bias comes writ large, as in the Walter Reed orthopod who pocket $850K and falsified his research to benefit Medtronic, and it comes writ small, as in the ER doc who sees a small lac and has to decide whether to use a band-aid or a stitch, knowing that the stitches will pay 10x more.  It comes with the cardiologist who has to decide whether to take a low-grade troponin leak to the cath lab.  It comes with the surgeon seeing a patient with unusual abdominal pain and a slightly enlarged appendix on CT (you can observe or just take out the appy; guess which pays more).

Whether there's a "fix" for that in the current reforms is debatable.  It harms our standing, however, to deny the possible existence of bias and to claim a moral purity that, as a profession, is not justified.  I think and hope that most of us in these ambiguous situations are able to come to the right decision for the patient the vast majority of the time regardless of our economic interests.  The best way to remain credible is to acknowledge the mere potential for bias and move on and debate the salient point.  Making counter-factual arguments that biases do not exist or that we physicians are too awesomely altruistic to ever be influenced by them does nobody any good.

How did I miss that?

In my post about "Zombie Lies" the other day, I mentioned this misleading point from the Investors.com article:

"The nonpartisan Lewin Group estimated in April that 120 million or more Americans could lose their group coverage at work and end up in such a [public] program,"

Jed reminds me of something which I knew but had forgotten:

It turns out the Republican Party has relied on and cited "policy analysis" from a "research firm" that is wholly owned by a health insurance giant:

The political battle over health-care reform is waged largely with numbers, and few number-crunchers have shaped the debate as much as the Lewin Group, a consulting firm whose research has been widely cited by opponents of a public insurance option.

To Rep. Eric Cantor of Virginia, the House Republican whip, it is "the nonpartisan Lewin Group." To Republicans on the House Ways and Means Committee, it is an "independent research firm." To Sen. Orrin Hatch of Utah, the second-ranking Republican on the pivotal Finance Committee, it is "well known as one of the most nonpartisan groups in the country."

Generally left unsaid amid all the citations is that the Lewin Group is wholly owned by UnitedHealth Group, one of the nation's largest insurers.

So there you have it: the Republican Party and the health insurance industry.

This has been another episode of "What Jed Said."

Stayin' Classy

I have never made but one prayer to God, a very short one: "O Lord make my enemies ridiculous." And God granted it. - Voltaire

Distributed by Florida neurosurgeon and member of the AMA House of Delegates, Dr. David McKalip:

He was contacted by TPM Muckraker:
McKalip said he believes that by depicting the president as an African witch doctor, the "artist" who created the image "was expressing concerns that the health-care proposals [made by President Obama] would make the quality of medical care worse in our country." McKalip said he didn't know who created it.

But pressed on what was funny about an image that plays on racist stereotypes about Africans, McKalip declined to say, instead offering to talk about why he opposes Obama's health-care proposals.

"I have a busy day," he said eventually, before ending the call.

Mmm hmmm. So that's all that he was saying -- that Obama's health care proposals would make health care worse. It had nothing to do with putting his head on the body of some savage negro-doctor! Nothing at all! But it is pretty funny, amIright? AmIright? C'mon! You got to see the funny.

Maybe if we could work watermelons into it somehow people would see how flawed the national insurance exchange concept is...


[UPDATED]
Dr McKalip initially publicly bristled at charges of racism, then backed down and apologized publicly, then sorta-privately blamed it all on the liberal media. Awesome.

Willfull distortions and demagoguery

With the admission that the Senate is for sure going to miss the August deadline for a vote on health insurance reform, it's looking certain that any final action on reform is going to last into October or possibly November. Which is a pity, because it means there will be that many more days in which I will have to knock down the misinformation, confusion, and deliberate mendacity of those who are opposed to reform. The reigning champion, by the way, is Betsy McCaughey, (the lady on the right with the SCARY TEETH) who seems to make her living by lying about health care. Seriously, she has got to be the least credible voice out there, which is why the WSJ op-ed page keeps going back to her every time they want to spread FUD. (Note to her publicists: you can stop sending me press releases every time she publishes something new. I'm on the other team.)

So, just for the record, here's the fisking of her latest hackery, published today:

GovernmentCare’s Assault on Seniors. - WSJ.com

H.R. 3200 and the Senate Health Committee Bill—will reduce access to care, pressure the elderly to end their lives prematurely, and doom baby boomers to painful later years.

Yes. In fact, the original name of the bill was the "Make Old People eat Cat Food Act of 2009," but they didn't like the acronym. Moving on:

The Congressional majority wants to pay for its $1 trillion to $1.6 trillion health bills with new taxes and a $500 billion cut to Medicare.

"Cut." Nice. We call it savings, but "cuts" sound scarier, don't they? Which is funny because isn't a common criticism of Medicare that it's too expensive/bankrupt/inefficient? Which is it? Should we cut find savings in Medicare, or should we protect it at all costs?

The assault against seniors began with the stimulus package in February. Slipped into the bill was substantial funding for comparative effectiveness research, which is generally code for limiting care based on the patient’s age.

Really? Damn, my decrypter must be broken, because I thought CER meant finding which treatments were most effective so doctors could make the best choices in providing efficient, effective care to patients.

In Britain, the formula leads to denying treatments for older patients who have fewer years to benefit from care than younger patients.

Every single ER doc I know despairs when we see the 90-year-old demented nursing home patient come in septic and in multi-organ system failure with family members insisting that "everything" be done. Some people are unable to admit when care is futile, and nobody wants to be the bad guy and say "no more," when families (or patients) are requesting inappropriate care. Betsy McCaughey apparently believes that we never will need to confront these hard choices, or that when we do, we are better served not knowing what the best options are.

White House budget chief Peter Orszag urged Congress to delegate its authority over Medicare to a newly created body within the executive branch. This measure is designed to circumvent the democratic process and avoid accountability to the public for cuts in benefits.

You hear that? Peter Orszag is the bureaucrat standing between you and your doctor! Damn. I had Kathleen Sebelius in the office pool.

Oh, and by the way, primary care doctors SUCK ASS:

The House bill shifts resources from specialty medicine to primary care based on the misconception that Americans overuse specialist care and drive up costs in the process. In fact, heart-disease patients treated by generalists instead of specialists are often misdiagnosed and treated incorrectly. They are readmitted to the hospital more frequently, and die sooner.

See, those silly liberals think that uninsured people need family doctors! It turns out all we needed were more electrophysiologists! And oculoplastic surgeons. And endoscopic urologists. etc, etc, etc. No disrespect to the specialists, but this is just insulting to PCPs. And it's straight out of Bizarro World to suggest that primary care is not in need of more support. This line of argument alone should disqualify Ms McCaughey from ever being taken seriously as a health policy commentator.

While the House bill being pushed by the president reduces access to such cures and specialists, it ensures that seniors are counseled on end-of-life options, including refusing nutrition where state law allows it. In Oregon, some cancer patients are being denied care by the state that could extend their lives and instead are afforded the benefit of physician-assisted suicide instead.

This paragraph is simply a work of art. Nowhere is there any supporting evidence for the claim that access is reduced -- I assume it's implied in the emphasis on primary care? But it's beautifully linked to the implication that OBAMA is going PERSONALLY SMOTHER YOUR GRANDMOTHER WITH HER HOSPITAL PILLOW. Actually, it's worse; he's going to stand there and smoke a cigarette while he FORCES HER TO SMOTHER HERSELF.

The harshest misconception underlying the legislation is that living longer burdens society. Medicare data prove this is untrue. A patient who dies at 67 spends three times as much on health care at the end of life as a patient who lives to 90.

Hmm. Possibly. Of course the medicare data ususally looks at the "last three years" of life. So that hypothetical 90-year-old who has the courtesy to die on the cheap, unfortunately, lived an extra 20 years longer and probably consumed a lot of medical care during that time. (This is, by the way, the reason Obama wants to smother your grandmother - to save money.)

This article really is a classic. It distorts the actual facts of the health care proposals, flat out makes up shit about primary care, scares the living bejeezus out of baby boomers gullible enough to think the WSJ Op-Ed page is as credible as the rest of the WSJ, and finishes with a modest propsal to fix everything by (wait for it) reducing access by increasing the eligibility age!

Ms McCaughey's opposition to Comparative Effectiveness Research, by the way, should in no way be assumed to be related to the fact that she is a current and former board member and still being compensated by medical device makers who stand to lose millions of dollars if their pricey devices were judged to be less effective than less-expensive therapies. No way, sirree. Nothing to see here, now move along....

'Cause I don't feel like writing anything original today

As conservatives and skeptics ask, "What's the rush?" to reform health insurance:

Crisis: Nearly Five Million Adults Have Lost Insurance Since Sept. '08

A survey of more than 29,000 individuals in June by Gallup shows that 16 percent of Americans over the age of 18 are currently without health insurance. That number reflects what the survey's authors describe as a "small but measurable uptick in the percentage of uninsured adults."

And our friends at Open Left remind us:

22,000 Americans die every year because they lack adequate health care coverage.

Strangely, after a two-year presidential campaign in which health care reform was a central issue for both parties, after reams and reams of policy papers and public debate, after seven months of active legislative work, and not to mention after sixty-five years of failed incremental reforms, now that we get down to the finale, all of a sudden reformers find themselves accused of "rushing."  Weird.

Meanwhile, Reuters channels KevinMD:

Shortage of doctors could damage healthcare reform

A growing shortage of primary care doctors could place a major burden on the U.S. healthcare system if President Barack Obama succeeds in extending medical insurance to millions of Americans who currently lack it.

As healthcare legislation works its way through the U.S. Congress, most of the focus has turned to how to finance it [...] Less attention has been paid to what might happen if millions of new patients join a healthcare system that is unprepared and unequipped to handle the load.  The United States already has a shortage of between 5,000 and 13,000 primary care doctors, according to the Robert Graham Center. Add millions of previously

Truth be told, for ER docs, not much would change but we would do much better financially.  The soon-to-be-insured folks come in to my ER now, and I see them for free.  Universal coverage won't decompress the ERs right away, but we'll be better paid.  More importantly, the on-call consultants who currently balk at caring for the uninsured will be more willing to provide ER back-up services, and hospitals might be better able to dedicate capital and operating resources to bolster emergency care.

On a stranger note, KevinMD channels, um, me:

Will the lack of primary care doctors make universal coverage useless?

[Shadowfax:] Both universal coverage and primary care reforms are necessary, but it is not an either-or proposition. Both must proceed on parallel tracks.

[Kevin:] Providing universal coverage is an imperative moral obligation, but one that must be accompanied by forceful cost control. Again, I point to the Massachusetts model as the example of what happens when universal coverage takes precedent above all else. [..]  Taking the politically expedient route, by promising universal coverage without strengthening the underlying primary care infrastructure first, will be doomed to failure.

Doomed, you hear that? DOOMED!  And I should point out that I agree on the cost control point, and I worry most about that aspect of all the reforms out there. Is IMAC our silver bullet?  Uber-nerd Peter Orszag thinks so:

IMAC, UBend

The Independent Medicare Advisory Council (IMAC) would be an independent, non-partisan body of doctors and other health experts, appointed by the President, confirmed by the Senate, and serving for five-year terms. The IMAC would issue recommendations as long as their implementation would not result in any increase in the aggregate level of net expenditures under the Medicare program; and either would improve the quality of medical care received by the program’s beneficiaries or improve Medicare’s efficiency.

As with the military base-closing commissions, this proposed legislation would require the President to approve or disapprove each set of the IMAC’s recommendations as a package. If the President accepts the IMAC’s recommendations, Congress would then have 30 days to intervene with a joint resolution before the Secretary of Health and Human Services is authorized to implement them. If either the President disapproves the recommendations of the IMAC or Congress passes such a joint resolution, the recommendations would be null and void, and current law would remain in effect.

This approach would free Congress from the burdens of dealing with highly technical issues such as Medicare reimbursement rates while rightly giving them, your representatives, a say in the matter. Moreover, this kind of body would enable the health care system to respond to a very dynamic market and technical landscape, making Medicare policy more responsive and effective in the future. All together, the IMAC proposal would make sure that there is someone always on the beat, looking for ways to bend that curve.

The Moonie Washington Times hosts three former AMA presidents who are hopping mad that the AMA endorsed HR 3200, but their credibility is undermined by the opening line of their op-ed:

Government threat to world-class medicine

We have the best health care system in the world. Most Americans live within an hour's drive of a world-class medical facility filled with expertly trained individuals and state-of-the-art technology delivering medical miracles every day.

You hear that?  You're within an hour of being able to look at a building where you could get health care if you're lucky enough to afford it. (h/t DKos)

Zombie lies

One thing that I have to give conservatives credit for is that they are always reading off the same script.  Sometimes hilariously so, as when Michael Steele ("the gift that keeps on giving") tried to talk health policy the other day.  He dutifully repeated all of pollster Alex Castellano's talking points, word for word, until when he had to take questions, when he finally admitted that he doesn't know his ass from a hole in the wall "doesn't 'do' policy."

But still, great message discipline!   That's always been their forte.  But it makes a tiresome chore to smack down all the odd lies they come up with, again and again, just like in the old zombie movies.  You give it both barrels of a 10-gauge, but it shambles forward mindlessly.  "Braaaiinssss..."

The one I have seem pop up most recently is the odd lie that the House Tri-Com bill (HR 3200) will "outlaw individual private coverage."

Huh?  I thought that's what the National Insurance Exchange was for?!  Where did that come from? 

I remembered that I had seen some crazy rant from Rep Michelle Bachmann (R-Loon) along these lines:

It’s over 1,000 pages long. On the 16th page, it says whatever health care you have now, it’s going to be gone within five years. So your current health care plan, you’re not going to have in five years. What you’re going to have is a government plan and a federal bureau is going to decide what you get or if you get anything at all.

And some commenters on Kevin's blog linked to this unsigned opinion piece from Investors.com:

It didn't take long to run into an "uh-oh" moment when reading the House's "health care for all Americans" bill. Right there on Page 16 is a provision making individual private medical insurance illegal.

How odd that they both cite "page 16" in their rants, both of which were published on the same day.  It's almost as if this were somehow coordinated...  Nah.  I must be getting paranoid.

The provision they are referring to, by the way, is this (edited for clarity/brevity, full text at the link):

SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE.

(a) Grandfathered Health Insurance Coverage Defined- Subject to the succeeding provisions of this section, for purposes of establishing acceptable coverage under this division, the term `grandfathered health insurance coverage' means individual health insurance coverage that is offered and in force and effect before the first day of Y1 if the following conditions are met:

(1) LIMITATION ON NEW ENROLLMENT- Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1.

(2) LIMITATION ON CHANGES IN TERMS OR CONDITIONS- Subject to paragraph (3) and except as required by law, the issuer does not change any of its terms or conditions, including benefits and cost-sharing, from those in effect as of the day before the first day of Y1.

(3) RESTRICTIONS ON PREMIUM INCREASES- The issuer cannot vary the percentage increase in the premium for a risk group of enrollees in specific grandfathered health insurance coverage without changing the premium for all enrollees in the same risk group at the same rate, as specified by the Commissioner.

(b) Grace Period for Current Employment-based Health Plans-

(1) GRACE PERIOD-

(A) IN GENERAL- The Commissioner shall establish a grace period whereby, for plan years beginning after the end of the 5-year period beginning with Y1, an employment-based health plan in operation as of the day before the first day of Y1 must meet the same requirements as apply to a qualified health benefits plan under section 101, including the essential benefit package requirement under section 121.

(c) Limitation on Individual Health Insurance Coverage-

(1) IN GENERAL- Individual health insurance coverage that is not grandfathered health insurance coverage under subsection (a) may only be offered on or after the first day of Y1 as an Exchange-participating health benefits plan.

So what does this mean in the real world?

1. Individual health insurance policies already in effect may continue but may not be altered.
2. Employer-sponsored plans have five years to get in compliance with the new regulations.
3. New individual health insurance policies will only be available through the National Insurance Exchange (NIE).

Remember, the NIE is where the private insurers will be competing against one another as well as against a possible public plan, if it survives.  It is not synonymous with a "government plan," though I hope that consumers will have the choice of a government-sponsored insurance policy.  The new regulations referred to are simply those I've outlined many times before -- community rating, guaranteed issue, and a minimum benefits floor.

The Investors.com piece is by far more blatantly dishonest.  For example, they stated, "those who leave a company to work for themselves [will not] be free to buy individual plans from private carriers."  But this is flatly false, since individual plans will be freely available through the NIE.  They also write, "a public option [...] will be 30% to 40% cheaper than their current premiums because taxpayers will be funding it," which disregards the fact that both the House and Senate bills make it clear that the public plan will be funded through premiums, not from general revenues.  If there is a price advantage to the public plan, it will be due to lower reimbursement to providers, not from taxpayer subsidies.  And the citation of "The nonpartisan Lewin Group estimated in April that 120 million or more Americans could lose their group coverage at work and end up in such a [public] program," ignoring that this estimate was not based on the plan as it currently exists, and the CBO estimated that only about 10 million people would choose the House's "strong" public option.   And as a sort of a coda, the author repeats the simply false claim, "What wasn't known until now is that the bill itself will kill the market for private individual coverage by not letting any new policies be written after the public option becomes law."  It's simply not true.  Private plans will be available, and competitive, through the NIE.  You can't get more dishonest than that.  

I should also point out that the wingnut echo chamber is resonating a little bit over this:

Morning Bell: Obama Admits He’s “Not Familiar” With House Bill - The Foundry

During [a conference call] call, a blogger from Maine said he kept running into an Investors Business Daily article that claimed Section 102 of the House health legislation would outlaw private insurance. He asked: “Is this true? Will people be able to keep their insurance and will insurers be able to write new policies even though H.R. 3200 is passed?” President Obama replied: “You know, I have to say that I am not familiar with the provision you are talking about.”

This was described as "disturbing" and evidence that the President is out of touch with the reforms he's advocating.  Right. I mean, wrong.  You see, he's not ignorant of the bill, he's just not familiar with the bits of it that exist only in the fevered nightmares of his political opponents.

And by the way, let's not make too much of the oft-repeated promise, "If you have health insurance, and you like it, [...] then you can keep it."  This is technically true, for a limited time.  He did not promise and it's foolish to think that it was promised that "If you have health insurance, and you like it, then you can keep it forever."  I don't have the health plan I had three years ago, and I'm sure I'll have a different one in another three years.  If you imagine that your insurance coverage was going to stay in stasis forever, preserved in amber, then you are frankly delusional.  We are all going to be under the new regulations sooner or later, and this is a good thing -- it is the whole point of insurance reforms.  For most of us, we will not even notice the changes, though it may get more expensive for some and cheaper for others.  But it is a distortion of Obama's intent to extrapolate that he promised that none of us would ever have to deal with changes.

OK, that was tiresome and annoying to have to deal with, but it's just part of the territory when you are dealing with zombie lies.  Now don't even get me started on the $23 Trillion bailout...

We know, but you're not supposed to admit it!

Politics Driving Opposition to Health Care Reform -- Taegan Goddard's Political Wire

n an interview on CNBC, Sen. George Voinovich (R-OH) admits that at least half the opposition to health care reform is about scoring political points against President Obama rather than substantive policy disagreements.

Said Voinovich: "I think it's probably 50/50."

And we continue to pretend that the GOP establishment is opposing reforms in good faith.

Sigh

If there's one thing I could criticize the Obama adminstration for, it is that they are insufficiently supportive of things that are AWESOME.

Apparently, today, the Senate complied with the wishes of the White House (and every military analyst, and the Department of Defense) and cancelled the F-22 Raptor program.  I mean, yeah, it was hugely expensive and we don't need it and it has no use in the current threats we face, but, but ... it is so fricking cool!  It can go supersonic without even being on afterburner!

Damn.



I also hear that they are taking a close look at NASA's Orion program, which is intended to return the US to the moon in the next decade; no decisions have been made, but Orion is AWESOME and thus I can only conclude that it, too, will wind up on the chopping block.



Sigh.

Can a brother get an amen?

Since Kevin prefers to title his posts as questions...

Should health policy be mandatory for medical students? | KevinMD.com

Although some schools give some token courses on the subject, the majority don’t. For instance, everything I learned about health policy was from reading medical and policy-related blogs over the past few years.

This piece from Slate gives one reason: medical students are too busy. Indeed, “Faced with a choice between learning about a high-paying specialty like radiology or gastroenterology or cardiology—all of which have limited residency slots—and public policy, there is no choice.”

Some schools, like Harvard Medical School, are taking steps to change that, by forcing students to take semester-long courses in health policy. And that’s a good thing. Doctors need to have a louder voice in the health care debate, since any reform has to potential to fundamentally change our professional lives.

Amen, brother! Amen.

They should also give course on the business of medicine, which is closely connected to the health policy field.  It's amazing how many doctors I interview who have no clue how a patient interaction turns into dollars.  Medical school is the only vocational education you can undertake which does not train you in the economics of the field you are entering.

Um, whose side are you on?

Fascinating ad from AHIP, America's Health Insurance Plans:

Did you watch it?  Notice anything interesting?  It sounds like an endorsement of ObamaCare: "if you lose you job," ... "if everyone is covered, we can make health care as affordable as possible," ... "the words 'pre-existing condition' become a thing of the past," cool.

The tagline is a dog-whistle to the political class, though: "Supporting Bipartisan Reforms that Congress can build on." Hmmm, "bipartisan" ... what could they mean by that?  Essentially, to the political types, this is a plea: "please don't include a public insurance option," while presenting a public face being pro-reform.

I'm not sure why they would do this, though.  From the consumer perspective, most people who see this ad will be more and not less likely to support reform, and would certainly not be calling up their centrist legislator to inveigh against a public option.  And the politicoes don't really care about ads anyway.  I think this ad actually helps Obama more than it hurts him.  And it's a sign that the prospects for reform are good when the best argument AHIP can publically make is a weak plea for bipartisanship.

Pre-existing Conditions and ObamaCare

Saw this interesting article from the LA Times:

Organ donors run risk of being denied health insurance

Eight years ago, Los Angeles resident Patricia Abdullah decided to donate a kidney to an acquaintance. She calls it one of the proudest moments of her life.

Now she wonders what will happen if she can't find another job with group coverage. If she turns to the individual insurance market, will her act of compassion as an organ donor be perceived by insurers as a "preexisting condition," resulting in higher premiums or even denial of coverage?

There was a dialogue on NPR with some expert about how this was unfair and wrong, but it made me think, and I don't entirely agree.   Under the current set of rules, if (and I stress the if) there is an actuarially-measurable risk related to prior kidney donation, it makes sense and is fair for insurers to price that into an individually underwritten policy.  Why wouldn't they?  Sure, you don't want to punish people for being altruistic, but Blue Cross shouldn't have to bear the responsibility for their insured's altruism.  Maybe the transplant center or Medicare or someone should cover the costs down the road.  I don't know.

But that got me reflecting on the notion of "pre-existing conditions" and then I read KevinMD's surprising and bold endorsement of the proposed ObamaCare:

[W]hat if reform doesn’t pass? It’s quite possible that preserving the status quo will be far worse for doctors going foward than the current proposals. I also believe that it’s important for doctors to “get a seat” at the table, lest they be marginalized further if they don’t.

I cited a quote from Paul Krugman a few months ago, where he wrote something along the lines of, “the perfect is the enemy of the good.” He was referring to the single-payer supporters and grassroot reformers who felt that Congress’ proposals didn’t tilt enough to the left, and as such, oppose the current efforts.

I think that sentiment goes both ways. Some reform is better than none, and doctors advocating for a free market-based system shouldn’t hold out, hoping for the perfect package.

It’s not coming anytime soon.

This also sparked some reflection on my part.  As the political wars have heated up, I've gotten deeper into the policy weeds especially with regard to the public insurance option, which has become the flash point between right and left. But here's a little perspective: if we lost the public option, but got the rest of the package, how would the reforms look?

The answer is: pretty good. 

Even absent the public option, the House and Senate HELP bills read like a wish list for liberals:

• Regulation of the individual and small group insurance market via a National Insurance Exchange
• Guaranteed issue (prohibits insurers from excluding people with pre-existing conditions)
• Community rating (prohibits ratcheting up the fees for those with pre-existing conditions)
• No recissions (prohibits insurers from rescinding the policies of people who become sick)
• Universal coverage via an individual mandate
• "Pay or play" employer madates to fund subsidies and encourage retention of employer-based coverage
• Sliding scale subsidies for those too rich for Medicaid but unable to afford insurance

And there's more, like the elimination of the SGR and the bonus payments for primary care.   If that's "all" we could accomplish in this reform year, then it would still be a big win.  And the great thing is that these key planks are now accepted by all major players as "done deals", and are assumed to be part of the final legislation.  The only points of contention remaining are the public insurance plan and the mode of financing.

Don't get me wrong: I still think a public insurance plan is a good idea and a critical element to include.  It will make the cost of reform go down, no question about it.  If we are going to "bend the curve" and try to rein in the escalating costs of health care, a public plan is necessary.  There are also some gaps that need to be filled, like the IMAC proposal, which might also help control costs.  So we are not done, and I hope Obama and the Democrats are able to keep the pressure on, hold their caucus together, and get a final bill passed with a mid-range public option intact.  It won't be easy, but we are on track and in as good a position as we could hope for at this point (albeit behind schedule).

Funny, but not "ha ha" funny

Saw a guy at McDonald's wearing this shirt:


It made me laugh.

Then I went to work and my first patient was a 54 year old man comatose with an ammonia level of 170 due to his liver failure.   Kinda kills the joke, doesn't it?

(and yes, it was alcohol-related liver disease)

Don't "Rush" Health Care Reform

That's the new meme out there since the "centrists" sent a letter to President Obama last week, asking for a slower pace for reform.  It's true that the process is so far behind schedule that the August deadline is looking less and less likely, a fact implicitly acknowledged by Obama in his weekly address, in which he reverted to his previous call for health insurance reform "this year."  Obama and congressional democrats had fervently hoped to have bills finalized and voted upon prior to the August recess; it is widely assumed that the anti-reform lobbies will use this fallow time to beat up on wavering centrists and increase their attacks on the as-yet undefined proposals on the table.  It is much easier to lambast reforms which are not yet finalized, since opponents can project their worst imaginations onto the bills without blatant dishonesty.  The conservative establishment will kick into high gear to drum up fear and doubt about "Government-run health care."  In the meantime, there will be few positive developments in the reform arena to drive a positive media narrative, and the reform will come to look more and more beleaguered.  The conservatives hope that when they return to Washington in September, they will have the votes to kill Obama's hopes for reforming health care.  Their tactic now is kind of laughable -- that the process has been "rushed." It started before the inauguration, and has played out over months and months.  Yes, there's an artificial deadline of August which gives the "rush" line some validity, but since that deadline looks blown anyway, the attacks are kind of meaningless.

Just to be clear: it is the fault of the democrats, in particular Max Baucus, that they are in this fix.  Much time has been wasted in trying to find a mythical pot of gold bipartisan solution to the vexing policy issues within reform: public insurance, financing, provider reimbursement.  Yes, it would have been nice if a truly bipartisan bill were possible, but it is becoming increasingly clear that the republicans in power are not interested in good faith participation in reform.  Senator Jim Demint (R-SC) spoke an accidental political truth when he said on a conference call with conservative activists: "If we're able to stop Obama on this, it will be his Waterloo. It will break him."  Bill Kristol was more detailed, but sent the same message:

With Obamacare on the ropes, there will be a temptation for opponents to let up on their criticism, and to try to appear constructive, or at least responsible. There will be a tendency to want to let the Democrats' plans sink of their own weight, to emphasize that the critics have been pushing sound reform ideas all along and suggest it's not too late for a bipartisan compromise over the next couple of weeks or months.

My advice, for what it's worth: Resist the temptation. This is no time to pull punches. Go for the kill.

This is where we are at: Republicans know that, as the minority party, their priorities will not be reflected in the health care reforms.  Worse, they know that successful reform will buoy Obama and the Democrats, and that the majorities the Dems enjoy in both houses will probably increase in 2010 if the democrats are given the credit for successful governance (and, hopefully, a recovering economy).  The Republicans are in a lose-lose situation, and their only win is to block reform and hope for a repeat of 1994, when Clinton's failure set the stage for a GOP takeover.  

So they play it out.  Their backs are against the wall, so they play for time in the hopes they can pull off a win. It's like basketball players fouling to stop the clock when they are behind.  For the GOP, their political calculus is that killing the reforms is the same as a win.  Stop universal health insurance, perpetuate the abuses of health insurance companies, keep WellPoint profitable, allow the explosion of health costs to continue, and 54 million Americans can stay uninsured for all they care.  The fact that there is a measurable human cost to keeping the status quo is irrelevant to them.  McCain ran for president under the admirable slogan "Putting Country First," but the GOP's stragegy now is "Putting Party First."

It's predictable, and it was predicted that we would come to this.  Fair enough.  The Dems in Congress should give up on a hunt for bipartisanhip that doesn't exist and they should pass their bill.  Let Ben Nelson and Joe Lieberman cast a symbolic "no" vote for the final bill, so long a they vote for cloture.  We can't afford to delay, and we can't afford to miss this opportunity.

That about sums it up (NSFW)

Only in Italy

The Guardian

But the patrol that pulled over a Ford Fiesta on Friday doing 112mph was surprised to find at the wheel a 56-year-old nun who claimed she needed to be at the pope's side after the pontiff lost his balance in the bathroom and broke his wrist. In the back were two fellow Salesian nuns, aged 65 and 78, who had jumped in the car in Turin when news broke of Pope Benedict's fall near Aosta, where he is spending his summer holiday.

My first reaction to this was "Really? A Fiesta can go 112 mph?"

Rationing, frankly discussed

Bab Wachter has a great opening salvo, well worth the read:

Wachter's World : Healthcare Rationing: Why Stalin Had it Right

I just finished a couple of weeks on the wards, and once again cared for several patients – cachectic, bedbound, sometimes stuck on ventilators – in the late stages of severe and unfixable chronic illnesses whose families wanted to “do everything.” As I wrote last year, there are limits (like chest compressions) on what I am willing to do in these circumstances, but they are mostly symbolic – basically, I am a bit player in this crazy house, with no choice but to flog the helpless patient at a cost of $10,000 a day in a system that is nearly broke and whose burn rate threatens to ruin our country. Go figure.

Is there anything we can do? The favored solution, a board resembling the UK’s National Institute for Health and Clinical Excellence (NICE) with the teeth to limit certain new drugs and technologies, is hard enough. But even if we were able to get a NICE-like organization in place (doubtful), that doesn’t really address the brutally tough issue: is our ethical model one in which we do everything possible, irrespective of cost, for every patient when there is any chance of benefit, or one in which we place limits on what we’ll do in order to do the most good for the most people. An American “NICE” isn’t going to limit ICU care for 80-year-olds with metastatic cancer. That will require a much broader public discussion, and even harder choices – since they will need to be made at the bedside.

Fun Links

Some good stuff out there in the health wonk world this weekend.

President Obama put the call out in his weekly address to "Seize the opportunity for health care reform, or lose it for a generation":

It's good. He stakes out some fairly clear turf on insurance company regulation and the public insurance plan:

That’s why any plan I sign must include an insurance exchange: a one-stop shopping marketplace where you can compare the benefits, cost and track records of a variety of plans – including a public option to increase competition and keep insurance companies honest – and choose what’s best for your family. And that’s why we’ll put an end to the worst practices of the insurance industry: no more yearly caps or lifetime caps; no more denying people care because of pre-existing conditions; and no more dropping people from a plan when they get too sick.

Better, he goes point by point in rebutting some of the zombie lies out there about the "government bureaucrats" and "socialized medicine:"

Finally, opponents of health reform warn that this is all some big plot for socialized medicine or government-run health care with long lines and rationed care. That’s not true either. I don’t believe that government can or should run health care. But I also don’t think insurance companies should have free reign to do as they please.

It won't convince those who pathologically insist that everything he says is false, but it's nice to see him finally taking on the fearmongers and liars who are attacking the plans.

Obama also takes on the Republicans: "The same folks who controlled the White House and Congress for the past eight years as we ran up record deficits will argue – believe it or not – that health reform will lead to record deficits.  That’s simply not true."

It's good to see the point made, as Yglesias does: Bush's unfunded Medicare part D cost $750 Billion, and his tax cuts cost $1.35 Trillion, and when it politically benefited them, the conservatives (and "moderates") happily ran up deficits.  Now that they do not stand to get the credit and the electoral benefit, suddenly fiscal conservatism is reborn.  What a bunch of cynical hypocrites.  Unlike the Republicans, however, at least the Democrats are trying to be responsible and develop funding mechanisms for their reforms.

In Newsweek, Ted Kennedy Speaks Out on Health-Care Reform giving a personal and passionate history of what he calls ‘The Cause of My Life’.  The key point he makes is how the drive for universal health care failed under Teddy Roosevelt, Truman, Nixon, Carter, and Clinton.  Put simply:

We can't afford to wait another generation

It's also a moving story of Kennedy's own experience as a consumer of health care, from a plane crash in 1964, to his childrens' battles with cancer, to his own current battle with brain cancer.  It's a long article, and leaves you with a sense of how deeply Teddy cares about this very personal issue he has worked on for so long.

White House uber-wonk Peter orszag points out the obvious: Opponents are using delays to kill health care reform

White House budget director Peter Orszag expects health care reform bills by August. Orszag says some are trying to slow down the process in an attempt to kill it. "The typical Washington bureaucratic game of — ‘if you don’t have a better alternative, just delay in the hope that that kills something’ is partly what’s playing out here," said Orszag.

You don't say.

Evolution Tales

Devilstower over at DKos (of all places) has a cool article about the evolution of horses, which he manages to link, in the style of Stephen Jay Gould, to the evolution of the Ford Mustang. Good storytelling, and worth a read.

Daily Kos: Mustang americanus

In 1874, Othniel Charles Marsh published a paper on the toes of horses -- a paper which is among the most widely reproduced, referenced, and adapted scientific findings in history. It may seem strange that a paper on a subject so esoteric should have such an impact, but timing is everything.

Charles Darwin's On the Origin of Species was published in 1859, and quickly became the focus of praise and controversy on both sides of the Atlantic. In his book, Darwin used a variety of living and extinct creatures as evidence in support of his theory of natural selection, but admitted that the fossil record was sparse and contained many gaps.

Critics immediately seized on this point, demanding that those favoring natural selection produce specimens that provided convincing support for Darwin's theory. Without the backing of "stones and bones," they declared that natural selection was little better than informed speculation. In particular, critics pointed at the lack of "transition" specimens in the fossil record. If creatures had undergone such astounding alterations over time, as Darwin's theory required, then why were the stones so full of things that seemed to be all this or all that?

(And don't worry; it's entirely nonpolitical. Even if you hate DKos, it's worth the read, and I won't tell anyone you were hanging out at the Great Orange Satan.)

Cronkite

BREAKING: Most, last trusted man in America dies.

Sadly, there's nobody on television news any more good enough to properly report Cronkite's death.

(h/t @TheOnion, and @pandagon)

Brilliant!

From the same geniuses who brought you the Homeopathic A&E.

Tools of the trade

Long, long ago, when I was a medical student, we joked that you could tell how senior a physician was by how much junk was in their lab coat pockets.  As students, we tended to carry around big bags full of every medical gadget we could think of, plus a few reference texts.  The attendings were slim and graceful in their long white coats with empty pockets.

When I became an intern and moved into the hospital full-time, all that crap became just too much to lug around.  I ditched the bag, and my short white coat (with interior pockets, thank god) became loaded down with tons of stuff: reflex hammers, pocket reference guides, photocopied research papers for reading, patient lists, a procedure log, a PDA with epocrates, a bit of a snack maybe, and more.  The coat weighed at least ten pounds fully loaded.  As a junior resident, I pared it down to the few references and gadgets I actually used frequently, and the coat got a lot lighter.  With each succeeding year I have lightened the load somewhat, down to the absolute essentials.  I shed the white coat years and years ago.  Now the only things I bring with me to the hospital are:

Three items.  It's very liberating.  Of course, I have epocrates and more on every computer workstation, so the references are there in the ER for me, but still, it's something of a victory over inanimate junk and my own packrat tendencies that I can go to work with only three things in my pockets.

The downside is that if I happen to forget any one of these three sacred totems, it totally ruins my whole day.

Good Point

One of the biggest objections I heaer to the various plans to reform health care, and to the public plan in particular, go something like "At a time like this, we shouldn't be..." (insert pet peeve: taxing payrolls, spending money, increasing the deficit, etc).  Kevin Drum makes a good point which I had kind of missed:

 Fighting the Zombies | Mother Jones

"At a time like this." I think I've read critiques similar to this about a thousand times now. I guess it sounds mighty clever, hoisting Keynesians by their own petard or something. But it's nonsense. The "pay-or-play" payroll tax increase doesn't go into effect until 2013 — and if the recession isn't over by then we've got way bigger things to worry about than a minor increase in payroll tax receipts.

Absolutely right.  I would argue that it's a bad thing that the most important features of the House bill don't go into effect till 2013, since the reforms are needed much sooner.  But if nothing else it should put to rest the "At a time like this..." objection, since if the economy hasn't recovered by then we'll all be living in caves and bartering gasoline for ammunition...

The Sustainable Growth Rate

It's a sign of exactly how big the health care reform bill that was handed down in the House that this did not make the Number One headline in the medical press:
It's Official: House Healthcare Reform Bill Scraps SGR -  MedPage Today

WASHINGTON, June 19 -- House Democratic leaders today unveiled a plan for healthcare reform that would overhaul the formula the government uses to calculate payments to physicians.

The draft bill, backed by Democrats in the three House committees with jurisdiction over healthcare, would replace the sustainable growth rate (SGR) with a new system that calculates payments based on care coordination and efficiency.

The new method "wipes away accumulated deficits, provides for a fresh start, and rewards primary care services, care coordination, and efficiency," according to a summary of the bill.

About time.

Now I would like to say that it's not clear at all what this means will be replacing the SGR formula.  I mean, I'm all for care coordination and efficiency, but how does one apply that to (for example) seeing a patient in the ER with a Boxer's fracture?  More to the point, will the new formula attempt to restrict the growth of physician expenditures as the SGR did?  This is what killed the SGR.  I never understood why Congress decided in 1997 that the rate of physician expenditure growth needed to be capped, but the costs for medical devices, hospitals, and drugs did not.   If they try to just stick another artificial cap on Part B expenses, we will just be in the same place in three to five years.

Yes, we need to reduce costs, no argument, but rigid and arbitrary restrictions on total expenses will not work. 

This seems significant -- AMA supports House bill and Public Plan

A nice new development:

American Medical Association Endorses House Health Care Bill | TPMDC

Just a couple weeks ago, the AMA was trying to have it both ways with the public option. The group had long opposed the provision, but in an appearance on CNN, its President J. James Rohack was unable to come right out and say so. Now it seems as if they've gotten over, or at least managed to suppress, their concerns. "On behalf of the Board of Trustees of the American Medical Association, I am writing to express our appreciation and support for H.R. 3200, the 'America's Affordable Health Choices Act of 2009,'" wrote AMA Vice President Michael Maves in a letter to House Ways and Means Committee Chairman Charlie Rangel.

I have to say that I'm a little surprised to see the AMA sign on at all, let alone so quickly.  There's certainly plenty of wiggle room in this endorsement, so they've not overcommitted themselves.  But it is a positive development from a historically regressive organization.

Let it be noted

I use Google Reader, and now they are annoying the hell out of me by telling me how many people "Like" an article I'm reading, and there's no way to turn it off.

Google Reader is not Digg, it's not Twitter, and it's not a fricking social media tool.  Knock it off guys, please.

I can see I'm not the only one to feel this way.

Runaway Jury Watch

(via Whitecoat)

Bronx Jury Awards 60 Million Dollars to Woman in Medical Malpractice Case

Alison Hugh went to Dr. Ofodile for a thigh lift procedure. As a result of the procedure, Ms. Hugh sustained significant injury and deformity to the labia of her vagina which is permanent and cannot be surgically corrected.

Dr. Ofodile failed to inform and provide Ms. Hugh with informed consent and failed to inform her of the risks involved in this type of procedure including the risk of vaginal opening and deformity. Dr. Ofodile failed to use proper surgical techniques by leaving too much tension in the skin of her groin area.

The Bronx jury found that Dr. Ofodile failed to appropriately advise Ms. Hugh about the risks of this type of procedure and that Dr. Ofodile deviated from good and accepted medical practices in his surgical technique.

The jury unanimously awarded Ms. Hugh Ten Million ($10,000,000) Dollars in past pain and suffering and Fifty Million ($50,000,000) Dollars in future pain and suffering.

Regardless of whether the patient actually suffered from negligence (as opposed to a simple unanticipated bad outcome, which is impossible to know), this is ludicrous.  $60 million.   Wow.  I've seen cases where the plaintiff died worth a lot less than that.  (Hell, that's less than the John Ritter case, isn't it?)

And this is just one of the many reasons why juries should not used to adjudicate in medical malpractice trials.

Culture Clash

One of the weird things about medicine is the hours we keep. They're kinda like "Banker's hours" only shifted three hours forward, and three hours back, on each end. I hadn't really thought about this much till recently, when a few events sort of reminded me of how the rest of the world works.

First, I went to a meeting of a charitable foundation's board I serve on. It's a big board with about thirty directors at least, and I would guess there are about five docs on the board, as it is a medical charity. One item of business was that the meeting schedule was being revised -- meetings were being moved from 9AM to 7AM, to better accommodate the physicians on the board. This seemed sensible to me and I was making the change in iCal when I noticed a lot of grumbling around the table. It seemed that everybody else was really unhappy about such an early start time. This sort of perplexed me, since 7AM is a perfectly normal time to have a meeting. I'm not in charge of this meeting, though, so I let it be and moved on with my day.

A bit later, I was at our business office, managing a few routine items with our office manager. As I left, I said "I'll see you tomorrow at the Board meeting." She responded with a sigh, "Yeah, bright and early at seven AM. Another early day." Again, sort of weird that someone would be visibly bummed about such a normal thing, but I didn't give it a lot of thought.

Then, I was trying to set up a meeting with our hospital's CEO to renew our contract. We were having trouble coordinating our schedules: he's very busy and I take a lot of vacations. Finally, in frustration, he suggested 6:00 one morning for the date and it worked for both of us, so there it was. A 6:00 AM meeting.

I mentioned this to my wife, who is what we call a "normal person," and her reaction honestly surprised me. "WTF? you have a meeting at 6:00 AM? Who the hell schedules meetings before seven?" It had never occurred to me that this would be an unusual time to have a business meeting.

My wife, an engineer by trade, set me straight. In the real world, nobody ever ever ever sets meetings before nine AM at the earliest. In fact, in the real world, most people start their work day at nine, not six or seven. Normal people can get up, work out, eat breakfast, shower, take the kids to school and still get to work on time. Weird. I've just been in the medical world fo so long that I kind of forget how everybody else lives. You get acculturated to 5AM pre-rounds and 7AM surgical start times in medical school, and after that you never look back. I'd kinda like to try that sort of lifestyle -- it sounds nice.

Just for the record, I was in the ER and seeing patients at 6:00 this morning. Some things will never change, I guess.

"Bipartisan" HELP Bill advances

Via Talking Points Memo:

The Senate Health, Education, Labor, and Pensions Committee has voted along party to move its health care reform legislation out of committee. The panel has been in mark-up for weeks now, and along the way, has approved 160 Republican amendments--and for all that largesse, not a single member of the minority voted in its favor.

Damn -- 160 GOP amendments approved?  I'd be interested in knowing what they incorporated into the bill there.  One interesting tidbit:
POLITICO Pulse

Under a Republican amendment approved Tuesday in the HELP bill, every member of Congress and their staffs would be required to enroll in the public insurance option. Sen. Tom Coburn (R-Okla.) authored the measure, which has become a rallying point for conservatives opposed to the public option. Sen. Ted Kennedy (D-Mass.), who voted by proxy, and Sen. Chris Dodd (D-Conn.) called their bluff and voted with Republicans to pass the amendment -- effectively neutralizing the issue for now. It seems unlikely that it would survive the many stages of the legislative process. Then again, Kennedy apparently likes it, according to his spokesman: "Sen. Kennedy believes strongly in the public option and its ability to provide quality and affordable healthcare while keeping the insurance companies honest. This was a no-brainer."

I like it.

And yes, for the irony-impaired, I'm using the "bipartisan" modifier somewhat facetiously.  It never fails to astonish me on some level that despite the dramatic compromises the Democrats have made in crafting this bill in order to please the conservatives, that the GOP seems bound and determined to dig their heels in and say "No, no, no."

I get letters

Not too many, and most are nice people with strange ideas, people selling something, or people wanting advice, but some of them just take my breath away:

"The most potent threat to the Obama administration’s fledgling health care plan may come not from the insurance industry or skeptical doctors but from the Congressional Budget Office. Earlier this week, CBO released preliminary estimates suggesting that the health care proposals [...] would cost $1 trillion and trim the number of uninsured by only 16 million."
nigga thats with a capital T. u need to check ur self before u wreck the country with dumb shit like that. obama (according to the c.b.o) spent 5.6 trillion dollars in his first month in office. on top of that he keeps spending money and investing in the wrong areas(ever here of pork). no matter how u implement a universal healthcare plan at this current time it is overwhelmingly econmically unsustainable.
p.s today's healthcare system sucks! now the question that remains is what better plan will work for the country.

I'm left speechless by this sublime piece, wondering if it could be an exceedingly subtle work of performance art. I mean, it can't be for real, right?

I'm also reminded of a great bit from The Princess Bride:

Similarly, that may be -- almost certainly is -- the first time in my life I have been addressed as "nigga." And in the context of a discussion of the Congressional Budget Office's score of health care reform and macroeconomics, it truly becomes a subversive thing of beauty. It's just not that common a term of reference in the health policy blogosphere (excluding Ezra Klein's blog, which should go without saying).

Anyway, this is a good time to point out that the House Tri-Com bill came out today, and it's even better than the Senate HELP bill, which was pretty good itself. (Note that the above commenter was apparently referring to the CBO score of the incomplete bill, not the final score, which comes much closer to universal coverage.)
Key facts in the early analysis of the House Bill:

• Cost: $1 Trillion (about $300B cheaper than the Senate bill).
• Coverage: 97% of Americans.
• Public Plan: Hybrid strong-weak. Starts off at Medicare rates + 5% for docs; but must negotiate after a couple of years; participation is voluntary; self-supporting through premiums; and must comply with same regs as private plans. The CBO estimates that the public plan would enroll less than 5% of Americans.
  
• Medicaid: only expands to 133% of FPL (as opposed to 150% in the Senate), and apparently lays groundwork for federalization of the program, which would be a huge boon to the states staggering under Medicaid costs.
• Subsidies: up to 400% FPL on the sliding scale.
• Individual Mandate: Present, enforced by a tax of 2.5% of AGI on those who do not purchase a policy.
• Employer Mandate: Strong. 8% of payroll in companies with payrolls greater than >$400K, exemptions for small businesses.
• Health Exchange: Regulates plans, run nationally, but states may opt out. No recissions, guaranteed issue, and community rating is required. Initially open only to individuals & very small businesses, but may expand later.
• Time Course: Phased in over three years, largely to save money on the front or less charitably, to hide the costs on the front!
• Financing: internal savings and surtax on the very wealthy.

There appears to be much more, such as filling in the Medicare drug price donut hole, etc. No, it's not perfect. To my surprise, it seems to be even more measured than the Senate Bill, and possibly even more do-able -- it costs less, covers more people, and even has less generous subsidies.

Better yet, there's a ton of overlap between the House and Senate Help bill, which is great news because now that these markers are down, it puts pressure on the more conservative Senate Finance committee to get in conformity or risk their bill -- and all their hard work -- becoming irrelevant. If nothing else, it's applying useful pressure on Baucus from the left. Well, the center-left.

And in this environment, I'll say that's good enough for me.

Chatting

Well, that was a ton of fun.  Thanks again to Kevin for having me, and I swear next time I'll try to be sober.

Oh, who am I kidding on that one?

Best bit: I managed to get in a James Joyce reference.  I had thought I had successfully expunged all Joyce from my head, but then it just came to me, like, well, like a stream of consciousness.

Cheers!

Reminder

I'll be live at KevinMD in less than an hour.  Head on over and ask me some questions!

It will be archived and visible there after the fact, if you're unlucky enough to be at the All-Star game or something.

Things not to miss

A couple of new items worthy of note:

First of all, the eccentric and erratic Dr Rob, The Distractible One, also known as "Llama-boy," has been granted that most coveted of spots, a weekly podcast in the Quick and Dirty Tips network!  (Yes, the one with Grammar Girl, and yes, I'm not ashamed to say that I listen to her, too.)  So get thee over to iTunes and subscribe (iTunes link) to the automatic downloads, else, I have it on good authority, Dr Rob has trained a team of ninja llamas in the deadly art of assassination...

Also, I have it on good information that he's nowhere as good looking as his Quick & Dirty avatar.  He looks more like Dr Evil in real life.

What?

The other item of note is that I will be engaging in a live chat tomorrow over at Kevin MD's site.  You can post questions and I will answer them in real time.  It's almost like I will be on the TV!  Except that you won't be able to see me, and there will be a lot more typos.   (A TV producer once told me that I have a great face for radio.  So much for my dreams of being the next Dr Sanjay Gupta and backing out of being Surgeon General.)  The chat starts at 10:30 PM Eastern, 7:30 PM Pacific, and the forum opens early for you to begin posting your questions.  I'll be getting an early start on the Bushmill's, so it should be plenty entertaining.  Topics are wide open, from ER stories, to EMTALA, to medical malpractice, to the seventeen reasons I'm such a pretentious twit.  I've promised to stay off politics unless Kevin gives me the green light -- and what're the chances of that?  So come on by and have some fun with it. I sure will.

Private Insurance, Explained Simply

Tom Tomorrow gets it right once again.

Peer Pressure

Everybody else is linking it:

It is actually laugh-out-loud funny.

Not dead yet

Been away from the blog for a while, what with some travel, holidays, and other real-life activities.  In fact, I've been totally unplugged from the Hive Mind, and it's been quite refreshing -- no blogging, no twitter, not even reading blogs, by and large. 
 


Most recently I was coaching a kid's sports development camp.  Fun and exhausting.  My kid's going on seven, so they put me with the 9-11 year-olds, wisely separating kids and their dads.  It was quite an eye-opener to work with the older kids -- they can actually play!  For example, in baseball, an infield grounder results in a routine 4-3 put-out, not a "little league home run," and in soccer these guys were shockingly good.  Most of them had been playing for years, and they had serious ball skills, even if they did tend to lapse into bunch-ball from time to time.  

Generally the coaches played in the games along with the kids; a great way to learn humility is to try to keep up with ten-year olds for thirty minutes on a soccer pitch.  Worse yet, as a reasonably athletic adult, I was not automatically the best player on the field, and maybe not even the second-best.  Sobering.

At the end, I could barely walk, but there was one last ritual: the coaches vs kids match.  It was a one-one tie, but they had a goalie and we played empty net and without about ten fewer players, so I'll call it a moral victory.  Ronny beat his own dad to score a goal, and after that the gloves came off.  It was awesome: no holds barred.  You haven't lived until you've seen a full-grown adult run over a ten year old to get to the ball, and I confess I totally trampled Carson while making a turn.  Nobody got hurt, and everybody had lots of fun.

And I still can't walk without a limp...

Photo Credit: TampaBay.com Blog

Great post

Proposition Disposition « Ten out of Ten

In residency you learn how to diagnose a supracondylar fracture. Out in the community you learn how to disposition it.

Happy Fourth of July

But really, folks, be careful with the fireworks!

Photo credit: Surfactant on Flickr

I never knew I was so powerful

Here it is, barely two weeks since I wrote in the New York Times that the best way to give doctors the right incentives was to reduce the pay for specialty-based procedural medicine and to increase the pay for primary care services.  And what happens?

Medicare Plans to Cut Specialists' Payments - WSJ.com
The Obama administration said Wednesday that it plans to cut Medicare payments for imaging services and specialists, and will use the savings to increase payments to physicians providing primary care.

Under the proposal, Medicare would put specialists' payments for evaluating and managing illnesses on par with those of primary-care physicians starting in January.

That, combined with other changes, would boost payments to internists, family physicians, general practitioners and geriatric specialists by 6% to 8% next year, said the Centers for Medicare and Medicaid Services

Wow. What should I wish for next? (Note to humor-impaired: this is facetious.  I may be paranoid, but I'm not delusional.)

Seriously, this is pretty good news.  Pediatrics, another poorly-compensated specialty will see a 4% increase, and just for the record, Emergency Medicine is pretty flat at 2% increase.  Hardest hit among specialists are Radiation Oncology, Nuclear Medicine, Interventional Radiology, Cardiology, and Radiology, all of which see >10% decreases in direct compensation.  This may in fact be understating the impact, in that the compensation will also be cut for certain diagnostic procedures such as echocardiography (-42%), coronary angiography (-24%), as well as the payments for CT, MRI and PET scans, and radiologists often (though certainly not always) own the equipment being used to perform the scans. The full proposed rule can be donwloaded here (PDF, 1128 pages -- pg 716 has the list), and is summarized here.

This is being accomplished in a variety of ways: Medicare will no longer pay for lucrative consultation codes, treating them instead as less-valuable Evaluation & Management (E/M) codes.  This is the big hurt for cardiology in particular.  The cuts in payment for radiology studies come from a change in the estimate of the utilization of the scanners, which were previously assumed to be in use only 50% of the time, but data showed were in use closer to 90% of the time; as a result the expected cost per study will be reduced.

There are also some minor fudges to the professional liability and practice expense components of the RVUs.

The good news is that this will help primary care docs and that is sorely needed.  The bad news is that the cost of this assistance seems to fall disproportionately on a few specialties.  My feeling is that the cost of a primary care bailout should be shared throughout the specialist world (yes, including Emergency Medicine if need be), not that the cardiologists and radiologists alone should fund it.  Under this plan, the compensation for general surgery, neurosurgery, orthopedic surgery, opthamology, anesthesiology and others actually go up, some as much as the primary care specialties!  And some "medical" specialties who do not perform a lot of procedures, such as oncology and allergy, wind up losing revenue.

It's also unclear to me whether this will be applied to all payers, or only Medicare.  Presuming that this change does not effect commercial payers, the net effect on primary care will actually be pretty small -- far too small to induce dramatic changes in physician compensation that are needed to drive physicians back towards the practice of primary care as a specialty.

So while the predictable histrionics are already beginning from the most affected specialty societies, it seems pretty clear that this is only a small first step and that further and more broad-based physician payment reform will be needed before primary care is restored as a viable area of medical practice.  And while I like the gesture towards acknowledging the importance of funding primary care, I'm not at all happy with the process by which CMS has arrived at this first step.  Worse, will it induce a sense of "fixed that, what's next?" which will preclude further revaluation of primary care services?   I dunno.  A for effort, guys, but minus ten points for execution.

The HELP bill

The Senate HELP (Health, Education, Labor & Pensions) Committee took a sort of a mulligan today after an embarrassing miscue last week in which an incomplete bill was released for scoring by the Congressional Budget Office (CBO) and came back costing a trillion dollars and covering less than a third of the uninsured.   That was a pretty big PR setback for reform, and generated a lot of right-wing talking points against the bill, but it was all pretty meaningless as it wasn't the final bill being scored.   Finally today, a more-or-less complete version of the bill (PDF) is out, and it looks pretty good.

Key features:

• Cost is in line with expectations at $1 to $1.3 trillion over ten years ($600 billion with an assumed $400-700B in expanding Medicaid to 150% FPL).
• Coverage is near universal, about 97% of population, with 21 million newly insured and 20 million more in expanded Medicaid.  Illegal immigrants not covered, of course.
  
• There is an employer mandate with a "pay or play" clause, with exclusions and/or credits for small businesses.
• There is an individual mandate with a meaningful penalty of not less than half the cost of insurance for those who can afford but do not purchase insurance.
• There is a "weak" public plan, which I think is a good thing, called the "Community Health Insurance Option."
• There is a limited health insurance exchange ("Gateways") administered by the states; these exchanges require community rating, guaranteed issue (i.e. no more pre-existing conditions exclusions) and prohibit recissions.  Very nice!
  

The Public Plan:

• Will be run by the department of Health and Human Services (which also runs Medicare).
• Will be voluntary for providers to participate or not.
• Will reimburse providers based on the average commercial payer rate in a region, which will be periodically renegotiated.
• Will be funded by premiums costs, not by taxpayer subsidies.
• Has "risk corridor premiums" to prevent dumping of sick patients into the plan.
  
• Start-up costs will be provided by the government in the form of a loan which must be be repaid over time.

Overall, this follows Chuck Schumer's principles for a "level playing field" public plan.  It won't get much republican support, I think, but it is clearly designed to rebut the criticisms that this is intended to be a back-door to a single payer system. 

While the public plan looks fair and good, I am a little concerned about the employer mandate.  The penalty for employers who do not offer insurance is $750 per employee per year, which is much more than the Massachusetts employer contribution but a lot less than the 8% of payroll that I've heard elsewhere.  However, even this weak mandate would supposedly generate about $50 billion towards subsidies for purchasing insurance for low-income workers.

The exchanges sound like they have some limitations on which employers or consumers can participate in them, which would limit their scope a bit, unfortunately.  And the subsidies in this bill aren't as generous as in the original draft -- they kick in at 400% of FPL instead of 500% as they did before, I think.

Sharp-eyed Orac notes that woo-meister Tom Harkin slipped in some free riders for purverors of snake oil and other alternative practitioners.

I have not seen any clear funding sources outlined as yet.

In terms of the pure politics, this is looking like the most likely to get enacted of the various plans circulating in Congress.  The House's bill is very liberal and has a strong public plan which would pay medicare-like rates. The Senate Finance bill is looking like a fairly conservative and less comprehensive bill. This may be the "compromise" position which finally gets through.  If this is what we wind up with, it's by no means perfect or complete, but it's pretty darn good.

Note:

I have not read the bill itself yet, so this is cobbled together from multiple sources.  Here they are for your edification and education:

Tim Foley Change.org -- probably the most comprehensive summary
Jon Cohn at TNR Here and Here -- he runs the numbers well
Politico
Ezra has more details
Igor at the Wonk Room

Is today Christmas or something?

Seriously, today must be Christmas, because Google Reader left a whole bunch of presents in my in box and I got everything I wanted!

• A Senate health reform bill out of the HELP Committee with a public plan!
• Increased payments for Primary Care!
• A partial fix for the SGR!
• Democrats finding their backbone!
• The AMA sort of supporting a public plan!
• Wal-Mart supporting an employer mandate!

(We're in "holy crap" territory here, folks.)

There's one lump of coal in my stocking, though -- "alternative practitioners" are included in the health reform plan.

There's so much wonky goodness, I'm going to split this into a couple of posts to discuss.  To follow shortly.

Milestone

I just noticed that sometime while I was away, the odometer cracked 500,000 unique visitors to this little blog.  I don't put too much emphasis on artificial metrics like that, but it's still pretty cool.  Once again, I am humbled and grateful that you take the time to come by and read my incoherent rantings.   Really, you're performing a public service, because without this outlet I'd be assaulting pedestrians on the streets and screaming at them about the public plan option.  So, well done!

Thanks again for visiting; knowing that you all are reading this keeps me honest and gives me motivation to put out the highest quality material I can.

The Central Line

The professional organization for emergency room physicians, ACEP, is slowly grinding its way into the new millennium.  They've made their Twitter debut, and also have created an on-line "blog," what ever the heck that might be.  It's cleverly titled "The Central Line," and perhaps not so cleverly, they have invited me to write for it.

Yeah, seriously.  I don't know what they were thinking, either.

So put it in your RSS feed; I'm still going to be posting primarily here, but will occasionally post stuff exclusively to The Central Line as it seems appropriate.  We are actively recruiting other EM bloggers to particpate, so some other familiar voices may be dropping by from time to time.

Blog fight!

Oh, man, I picked a fight with Ezra and he got all wonky on me, even with a chart.  Oh Noes!  Not a chart!  And ... it's actually a pretty interesting chart.  Here it is:

First of all, just for the record, let it be noted that my previous post was entirely about Medicare's under-reimbursement of physicians, and Ezra's clearly going all Willie Sutton and going where the real dollars are: facility reimbursement.  Fair enough, though I'll disclaim that I'm not nearly as well-versed in hospital reimbursement as I am in the professional side of the Medicare fee schedule. 

The above graph would seem to disprove Ezra's original thesis, that hospitals continue to participate in Medicare because it is profitable for them to continue to do so.  As you can see, there's rampant cost shifting, as Medicare pays only 92% of the actual costs of inpatient care whereas the commercial payers are in the high 120s%.  Right? 

Well, yes and no.  The lifeline in this case is some very interesting testimony by the head of MedPac regarding a small subset of hospitals (about 12% of all hospitals) who were actually able to eke out a positive margin (0.5%) on Medicare payments in 2004-2006.  The contention is that since these hospitals were able to do so, and with higher quality than the other 88% of hospitals, that the hospital industry in general is inefficient and if they were only able to get their act together Medicare payments would be sufficient to support a viable hospital industry.

The key factor which Ezra elides over is that these hospitals are in the "financially pressured" category.  There doesn't seem to be a definition or cross-tabs on what exactly "financially pressured" means, but these hospitals actually have a worse operating margin on their non-medicare business (-2.4%).  Given that, it's fairly safe to conclude that this means hospitals with crummy payer mixes -- high medicaid and uninsured, low numbers of commercially insured patients.  This occurs most commonly in rural and inner-city markets -- underserved areas in which there is usually one hospital at best.  These undesirable markets do not encourage other providers to enter and compete for customers and so the hospitals there tend to undercapitalize, willfully or no, and offer bare-bones services.  That some fraction of "financially pressured" over-perform on outcomes is not explained in the testimony.   It could be a statistical aberration, or cherry-picked data; giving credit to the integrity of MedPac, it might be due to the exceptional leadership that some of these financially stressed hospitals have developed.  The testimony does not reveal what fraction of "financially pressured" hospitals outperform on quality measures -- if less than 50% of "financially pressured" hospitals outperform on quality, it would imply that the under-funding of these facilities harms quality of care more than it helps.  Note that those that outperform have substantially worse margins (0.5% vs 4.2) on Medicare payments, implying that there is some linkage between higher expenditures and better outcomes.

I am gallant, however, and I will concede the key point here: hospitals which are well-funded do tend to be inefficient.  Specifically, areas with enviable payer mixes are generally served by multiple hospitals and those hospitals compete for patients and revenue by over-capitalizing and improving amenties and customer service.  This is just another example of the perversion of the market in which patients do not directly bear the costs of their health care decisions. 

Coming back to the original point: if Medicare were such a lousy payer, hospitals would opt out, yet this never occurs.  Interestingly, the well-heeled suburban hospitals who lose the most money on Medicare patients are the least likely to opt out of Medicare.  They have such high margins on their commercial patients that they can view Medicare as their charity contribution to the community.  On the other hand, the financially pressured hospitals do better on Medicare than the rest of their payers, so Medicare is their economic lifeline.  Or, more formally, the value of Medicare patients to a hospital varies inversely with the number of commercial patients in their payer mix.

Ezra's conclusion here is that we need to cut costs, hospitals are in many cases inefficient, and so we should just reduce payments to them until they feel the pain and dial it way back.  As my old medical director used to say, "We're building a Buick, not a Cadillac." But there are many problems with such a strategy.  For one, the hospitals most dependent on Medicare would be harmed most by reductions in payments.  While workarounds could be crafted for financially stressed hospitals, it's unclear what effect reductions in payments would have in quality, but it would be hard to imagine that quality in general would improve.  And it's not clear to me that this really addresses the key drivers of cost: wasteful and redundant care, as opposed to more-expensive-than-it-needs-to-be inefficient care.  Given the volume incentive of the fee-for-service game, reductions in compensation usually just drive increases in utilization, not the other way around.

Ultimately on this point, I have to concede ignorance.  I know that the Medicare Professional Fee Schedule for phyicians is woefully inadequate and needs to be increased.  I do not know if the same applies to the hospital fee schedule -- I'm just not well-enough versed in the economics of that game.  I should point out that while medicare payments to physicians have been essentially frozen since 2001, the facility fees, unconstrained by the SGR, have risen year over year to keep pace with inflation.  I never did see any disagreement with my original points, by the way, that for professional services, the underfunding of Medicare is leading to decreased access as physicians close their practices to new Medicare patients, and that hospital-based physicians are unable to opt out due to the nature of their realtionships with the hospitals who employ them,

Thank you

This has been bugging me for a while now: I can't write about the proposed health care reforms without some twit in the comments or an email writing that "Obama's" plan is going to ... [insert various calamity here].

As usual, it takes Nate Silver to make the point clearly:

FiveThirtyEight: Politics Done Right: Obama Has a Health Care Plan?

CNN asked a stupid question and got a stupid result:

From everything you have heard or read so far, do you favor or oppose Barack Obama's plan to reform health care?

51% Favor, 45% Oppose

OK, so in fact there's nothing stupid about the question at all. The public's response, likewise, is perfectly reasonable given the information they were provided.

But a better question might be: what exactly is Barack Obama's health care plan? Does he have one?

And if so, what's included in it? Is it the plan Obama advanced on the campaign trail, which had a public option but lacked an individual mandate? Is it the one making its way through the Senate Finance Committee, which has an individual mandate but lacks a public option? Is it the House's version, which has both?

Yes.  Obama himself doesn't have a health reform plan.  There are a zillion proposals floating out there, many of which have been explicitly or implicitly endorsed by Obama, some of which have features favored by Obama, but none of which were crafted by Obama or anybody in his administration.

This may be bad politics, as Nate goes on to suggest, because it allows critics to attack his plan (which doesn't even exist).  On the other hand, Clinton famously took a micromanaging approach with congress in his attempts to reform healthcare with disastrous results.  I'm not sold on the "right" way to go about it, politically, either way.

But one thing which is pretty clear to me is that the critics who make blanket statements against "ObamaCare" are either ignorant or not arguing in good faith.  A lot of critcics, to their credit, are on-point, and make good policy arguments against specific provisions such as the public plan or single payer or what-have-you.  But the majority, I'm sorry to report, seem very clearly in the "whatever it is, I'm against it" camp.  And that has no credibility whatsoever.