30 April 2009

Obama on Health Care

A couple of disparate points from Obama himself recently on health care:

He's open to medical malpractice reform as part of compromises in the larger health reform package:
"I've said this to people like Mitch McConnell," he recalled. "I said, look, on health care reform, you may not agree with me that we should have a public plan. That may be philosophically just too much for you to swallow. On the other hand, there are some areas like reducing the costs of medical malpractice insurance where you do agree with me. If I'm taking some of your ideas and giving you credit for good ideas, the fact that you didn't get 100 percent can't be a reason every single time to oppose my position."
Maybe it's just a posture.  Congressional prospects for liability reform are not terrific.  But nice to see that he recognizes the need and is willing to say so publicly.  Also good to know that he is still emphasizing the need for a public plan option, a point also emphasized by the letter 16 Senate Democrats (some of them surprising) sent to Baucus and Kennedy yesterday urging them to retain the public plan as the negotiations continue.

Jonathan Cohn at TNR highlights a couple of key exchanges from Obama's extended interview.  In the first, Obama discusses the asymmetry of information that will prevent consumer-directed health care from achieving the cost savings some hope it might:
OBAMA: ...we should not overstate the degree to which consumers rather than doctors are going to be driving treatment, because, I just speak from my own experience, I’m a pretty-well-educated layperson when it comes to medical care; I know how to ask good questions of my doctor. But ultimately, he’s the guy with the medical degree. So, if he tells me, You know what, you’ve got such-and-such and you need to take such-and-such, I don’t go around arguing with him or go online to see if I can find a better opinion than his.
And in the second clip he discusses the challenges surrounding costs in end-of-life care:

OBAMA: ...I actually think that the tougher issue around medical care — it’s a related one — is what you do around things like end-of-life care--

LEONHARDT: Yes, where it’s $20,000 for an extra week of life.

OBAMA: Exactly. And I just recently went through this. I mean, I’ve told this story, maybe not publicly, but when my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip. [... long clip cut...] There is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels.

This is a huge issue that no prominent politician has dared to broach, in my memory.   He doesn't have answers, but he's raising the right questions.  We will see if there's a will out there to start filling in the right answers.

Physician Compensation -- an End-run

I had an off-the-record conversation with a member of the RUC earlier this year -- not necessarily an Emergency Physician, but a member familiar with the strategies of the alliance of cognitive physicians. I asked him whether there was going to be another rebalancing of the RVU system to favor primary care, as there was in 2006. He indicated that the primary care lobby had essentially given up on the RUC as irredeemably corrupt (OK, maybe that's just my interpretation of what he said) and that they were going to be going directly to CMS to ask for additional payments.

It seems that strategy has borne its first fruit. Senate heavyweights Max Baucus and Chuck Grassley have a bipartisan proposal which would increase payments to PCPs by 5% while reducing payments to other physician specialists, in order to offset this in a budget neutral fashion.

Predictably, the specialty societies will fight this hammer and tongs.

In my opinion, the 5% bonus is probably inadequate -- it should be at least 10%, and I say this as a member of a specialty that will probably not be considered primary care for the purpose of this payment. The RVRBS was created and is periodically rebalanced based on the concept of rewarding physician work, which seems fair on the face of it. It's pretty indisputable, however, that the formula has become skewed so far in favor of procedural medicine that short of a wholesale rethinking of the system it cannot accomplish the policy goals that it is supposed to.

The physician compensation system needs to be reoriented not to reward "work" but to create the incentive for physicians to fill the roles which our health care system needs.

We need primare care docs more than we need ENTs (for example). No disrespect to ENTs; I greatly appreciate their services when they come to the ER and stop a tricky nosebleed or drain a peritonsillar abscess. It's important work. But the number of people who will suffer from a shortage of ENTs (or urologists, or orthopedists, etc etc) pales in comparison to the number of people who are and will suffer from a lack of primary care. If the President is successful in providing health insurance to 47 million more Americans, then the current shortage of PCPs will become much, much worse. In order to encourage physicians to pursue these necessary fields, the incentives need to set such that the earning potential for a subspecialty surgeon does not so greatly exceed that for an office-based physician.

People are rational actors and repond predictably to incentives. Perverse incentives, such as we currently have, result in perverse outcomes, such as the fact that only 2% of medical students currently intend to specialize in primary care. The incentives need changing.

Some have argued that we should just pay the PCPs more, without reducing specialty compensation. To that, I would say first that such a change would likely not achieve the desired goals. Currently, it's possible to make two or three times an internist's salary as a surgeon. Unless you increase the PCP's income by a large factor, that income gap is going to remain large. Bringing one up and the other down, however, will more efficiently neutralize the disparity.

More to the point, in the current system of health care approaching 17% of GDP, it's completely unrealistic to expect that Congress will allow physician reimbursement to go UP. Every stakeholder at the table has made major concessions (or will be asked to). The insurers are accepting community rating. Small businesses will be hit with pay or play. If this is the bitterest pill that doctors are asked to swallow then we will be getting off easy. It is the sheerest fantasy to think that we can lobby for a pay increase.

If the proceduralists fight this, they are going to lose. How do I know this? I don't, but in my recent visit to Capitol Hill, I spoke with no fewer that nine members of congress and/or their health policy directors (all democrats). All of them have the "primary care" mantra down pat. It was encouraging given the state of primary care to see that they understand that it needs to be a priority, even if it was frustrating as an advocate for emergency medicine to try to educate them about the needs of the acute care system.

This proposal by Baucus and Grassley is encouraging even if it is a kludge-y workaround of the failure of the RUC. It would have been better to abolish it and re-invent the RVRBS, because the formulas are still terribly flawed. This is like the annual SGR patch, a temporizing measure that kicks the can down the road a few years -- which is forgivable given the scope of the reforms they are currently contemplating. Ultimately, fundamental physician payment reform is still necessary.

29 April 2009

Compelling Health Care Workers during a pandemic?

From, I think, the Iowa Law Review and Seton Hall University School of Law:

Beyond the Call of Duty: Compelling Health Care Professionals to Work During an Influenza Pandemic
In anticipation of pandemics and other mass disasters, several states have enacted little-known laws that authorize government officials to order health care professionals to work during declared public health emergencies, even when doing so would pose life-threatening risks. Health care professionals who violate these orders could face substantial penalties, ranging from license revocations to fines and imprisonment. The penalties would apply even to individuals whose jobs do not normally involve clinical responsibilities, as well as to health care professionals who are retired or taking time off from work to care for their families.
Yikes.  I was not aware of these laws -- wonder if my state has one?  That'll be real popular.

I wonder if this could backfire.  Health professionals tend to be pretty altruistic and public-spirited, especially in times of crisis.  I would expect that the response from workers would be pretty positive.  But if the state were to start forcing people to work, then that public coercion would probably reduce the motivation for doctors and nurses to volunteer.  Which could be a sort of catch-22, since the state would probably only invoke this power if the response from health care providers was inadequate in the first place.

I'd actually be interested in reading that entire article.  Looks like only the abstract's available on line.

100 days

Barack Obama sent Somali Pirates a Trio of Snipers - Slate Magazine
News organizations have done an admirable job of recapping the first 100 days of the Obama administration. But rarely do we stumble across a primary source like Barack Obama's own Facebook feed. Scroll down for the full story.


Safety valve or competitive threat?

A good point on ERs from the LAT (which has been running a nice series on ERs lately)

ERs face a new urgency - Los Angeles Times
As emergency room visits in the United States have ticked steadily upward, reaching 119.2 million annually, waiting for treatment has become a central feature of emergency-department care.

Patients spend an average of 3.3 hours to be seen, treated and discharged, according to a 2006 report by the federal Centers for Disease Control and Prevention. [...] Instead, a growing number appear to be voting with their feet. Those walk-in patients are fueling the growth of a kind of healthcare provider now making a comeback -- the urgent care center -- and at some hospitals, a flurry of efforts to improve the ER experience.
Since the "walking wounded" are generally the easiest, fastest and most profitable cases in the ER, it behooves a hospital to have a functioning fast track to shuffle them through quickly.  It decompresses the waiting room, improves patient satisfaction, and frees up resources for the truly ill.

Urgent care centers have the ability to skim off only the paying patients, since they have no EMTALA obligation, and some are well-equipped with all the ancillary tests available at an ER -- up to and including CT scans.  In fact, the ancillary tests are the profit centers of an UCC, with the clinic itself being something of a loss leader.  It's an attractive option for patients -- cheaper, faster, more service oriented.  It's probably better policy on a national scale, since it's a better use of resources.  But if all the fast track patients leave the ERs and go to UCCs, then something would have to change.  Some new source of funding would have to be found to support the newly financially unviable ERs.

Swine flu update

The Daily Show With Jon StewartM - Th 11p / 10c
The Last 100 Days
Daily Show
Full Episodes
Economic CrisisFirst 100 Days
Jason Jones, at the "Center for Stuff I heard from Some Guy"

As usual, nobody does it better than the team at the Daily Show.


I saw something recently which I have seen only once before, as a medical student.  It's really quite rare in this day and age, but the presentation was so classic that I knew it practically as soon as I laid eyes on the patient.  I was very satisfied to make the clinical diagnosis in advance and be proven correct by the work-up.

The Chief Complaint was "shortness of breath;" the patient complained of trouble breathing when he laid down, and some extremity swelling, so I kind of assumed that he had CHF.  He was about 60, and had no significant medical history, and the vitals looked fine.  The only odd thing I noticed that that he complained that his face was swelling, too.

The interview wasn't much more revealing than that.  He had a dry cough and diminished exercise tolerance, but not a lot of other symptoms.  No fevers or chest pain.  He was losing weight, which I thought was odd in a potential CHFer, who usually gain weight as they retain fluid.  He was a long-term smoker.  Also, he added, there was a sense of fullness in his neck that he thought was really uncomfortable, and that's what made it hard to breathe when supine, because he felt like he was choking.

The exam was noteworthy for facial swelling and edema, with a distinct dusky flushing in the skin color.  The neck was diffusely swollen, but I could not make out any lymph nodes or cords or other masses.  The neck veins were very prominent (which is defined as "the ER doctor noticed them").   Strikingly, there were varicose veins in the shoulders, chest, and upper extremities, all of which were distended, and indeed, the upper extremities were swollen and shared the same dusky color as the face.  The skin below the chest was normal in color, and there was no swelling or abnormality in the lower extremities.

I'll skip the x-ray and go straight to the CT (click images to embiggen):



Uploaded with plasq's Skitch!

What we have here are images of the chest with IV contrast.  The contrast shows up as bright white, mostly inside blood vessels. The contrast was injected through an IV in the right arm. There is a mass adjacent to the right hilum, probably an invasive bronchogenic carcinoma.  This mass is compressing the superior vena cava (SVC), which returns blood from the head and arms to the heart.  It's the main vein in the chest, thin-walled and usually a couple centimeters in diameter.   The SVC is almost completely effaced in the top picture, and reduced to a millimeter in size in the middle one.

The obstruction of the vena cava causes increased venous pressure in the arms, head and neck, which is responsible for the dusky color and swelling.  The fullness in the neck is probably from massive distention of the jugular vessels.   The increased venous pressure causes blood to find alternate pathways back to the heart, in this case through venous collaterals, mostly subcutaneous.  You can seem them in the right armpit (on the left of the picture) and under the skin in the front of the chest, all bright white.

This is called SVC Syndrome, and given the early detection of lung cancers these days is pretty uncommon (also, syphilitic aortic aneurysms and tuberculosis are less common than in the past).  This patient had all the classic symptoms and clinical findings.   The tumor has to get pretty big to compress the Vena cava.  This patient did note that his cough had been going on quite a while, but his policy of "seeing the doctor ever ten years, whether I need it or not" turned out to not be the best one.  His 60+ pack-year history of smoking didn't help, either.  This is a pretty terrible diagnosis for the patient.  It's too early to say, but this looks like a non-survivable lesion.

My six-year old asked me the other day: if smoking is bad for you, why do they let you do it?  We had a little conversation about freedoms which was quite frankly over his head.  Little kids are too used to being told what to do to understand the concept and value of liberty.  He came away firmly convinced that it should be a rule that you're not allowed to smoke.  After I had a very difficult "you have cancer" conversation with this gentleman, his wife and three daughters, it was hard not to agree with my six-year old.

This is also one of the weird contradictions of being an ER doc.  I was, I admit, pretty juiced about this case.  It was rare and I was very satisfied about making the diagnosis.  But it was also awful for the patient.   I remember something one of my teachers taught me in residency: "Never forget that your best day is by necessity someone else's worst day."

27 April 2009

Comparative Pharmacology

I wrote earlier this month on the regional variations between the different types of heroin we see out west vs back in the midatlantic region. One interesting thing that I would note is that we just don't see much heroin use out where we are, at least not on a comparable basis. Nor, now that I think of it, do we see much cocaine use. I think part of this is that we are in a suburban location -- not the affluent suburbs by any means, more of a gritty, blue-collar exurb -- but a suburb nonetheless. When I do see someone who admits to cocaine use in particular, they are quite commonly "visiting" from the Big City directly to the south of where we work.

This, by the way, is not some sort of racial code. The Pac NW is a very different mix, ethnically, than anywhere I have ever worked in the past. Mostly white, with a lot of Asians and Pacific Rim folks, Ukranian & middle easterners (lotsa Iraqis), some Hispanics, many Native Americans, and only a small amount of African-Americans. In sharp contrast to the highly segregated drug use patterns I have seen elsewhere, there does not seem to be much racial differentiation in the patterns of drug use here. There is, of course, a high degree of economic correlation with drug use, which I suspect is more of a universal pattern, but I still see an urban-suburban local pattern too.

But I digress. Again. What we do see it lots and lots of methamphetamine use. One of the small towns near here was once dubbed the "meth capital of the US" and meth lab busts used to be a daily occurrence. That's not the case any more, since the severe restrictions on sudafed sales went into place. Sudafed is a key ingredient in the manufacture of meth. This really drove a reduction in the home manufacture of meth, most of which, I am now informed, is imported from mexico, where sudafed is available in mass quantities and industrial, high-grade meth can be manufactured on a large scale. Ironically, this is partly a good thing, since meth is made with anhydrous ammonia, which is quite dangerous. Decontamination is a big problem both for the ER and for the police when they do have a meth lab bust; explosions/fires were also fairly common. Score one for globalization!

The acute issues with meth are very different and more intractable than heroin. With heroin, folks come in with infectious complications of injection, which are straightforward enough to manage. Sometimes they come in with withdrawals which are miserable but not dangerous, and most commonly treated with anti-emetics and time. Sometimes they come in with overdoses which can be tragic but are very straightforward in their management. There are detox centers which are comfortable and familiar with heroin withdrawal, so if there happens to be funding and availability, it's easy to get them into treatment.

Not so with meth. The most common meth presentation is a patient commonly described as "tweaking." They are the folks who have been using heavily and represent a real challenge in the department. They are jittery and nervous, hyperkinetic and very talkative. If they're really been on a bender, they may not have slept for several days and they may be getting paranoid, confused, and delusional. Often, the reason that they were brought into the ER is that they have started to come apart at the seams, mentally and have crossed the line into full-blown psychosis. There is absolutely nothing you can do to calm them down or reassure them. Trying to redirect a restless paranoid tweaker is an exercise in futility, and a constant struggle.

So what do you do? No psychiatric facility will take them for admission, since their psychosis is purely due to the drugs (and psychiatry's ability to treat that is minimal). Most detox facilities won't take them either on the theory that a) there's no withdrawal syndrome from amphetamines and b) they require so much personal attention while tweaking that the detox places simply can't handle them. Families are also reluctant to take a tweaker home, either because they've burnt their bridges or, again because they're such a handful.

So that leaves me in the position of streeting them or keeping them. If the symptoms are mild and there's no cognitive impairment, then it's perfectly OK to discharge them back to their own recognizance. It's frustrating, but we all know there's nothing else to do. On the other hand, most people don't come to the ER because their symptoms are mild. So I get to play policeman and restrain them for their own safety until they are back to their normal selves. That gets real fun. Four-point restraints are the first line, while we check them out medically to make sure there's nothing else going on. Oh boy, that can be a real rodeo! Put a tweaker in restraints and the volume of the department goes up by 400%. And worse, it's dangerous, because the typical person high on meth will not stop struggling against the restraints no matter what. I've seen docs who just shut the door and ignored the hollering tweaker until the next shift came in to find the patient dehydrated and in rhabdomyolysis. Not a good idea, and though I have never seen it, this has been thought to be the cause of deaths in some police cases, due to "excited delerium." And like the PCP guys of yore, they don't feel pain like normal people do, which makes them dangerous when they try to escape. I've a black belt in karate, and many's the time I've had to utilize it to help restrain a tweaker (note: joint locks have their uses!) who was trying to get away before security could get there.

So you wind up sedating them in most cases. You have to be careful in how you dose the ativan (haldol works too, but is harder to titrate). If they are full-bore tweaking, it may take many doses to get them calm. On the other hand, if they've been high for a few days and are ready to crash, just a little bit can put them in a deep, deep sleep. Once they go to sleep, it's possible for them to be nearly unarousable for 24 hours as their bodies repay their sleep debt.

Meth is an evil, evil drug. I used to think that heroin was the most evil drug ever created. Heroin has a way of getting a hold on your soul in a way that, once an addict, you can never be free. One of the most searing books I ever read was The Corner (amzn) which told the story of a year in the life of an inner-city neighborhood ravaged by heroin, and the people whose lives were ruled by that drug. Understand that I am not minimizing the impact of heroin. But it is possible to live a normal, productive life despite being a heroin addict. I have seen sixty-five year old grandparents who got hooked as GIs in Vietnam and have used daily ever since. It's uncommon -- you need to avoid jail, getting shot, overdosing, HIV, tachyphylaxis, withdrawal and more. But it is possible.

Not so with meth. Meth destroys the mind in a way distinctly different from other drugs. The chronic users who come in are awful to see. When not high, they shamble, vacant-eyed and apathetic. Their speech is simple and sparse of content. Their affect is blunted. It's like something happened to their frontal lobes -- whether they have been destroyed, or just turned off I can't say, but they look and act like people who have had frontal lobotomies. It's hard to imagine how a meth user could ever be rehabilitated into a functional member of society again. I say this not to be judgmental or prejudicial, but to emphasize the degree of intellectual impairment these folks exhibit. And it's so sad, to think that this young person was just a couple of years ago a typical high-school sophomore. And the transformation into the cadaverous specimen is appalling.

Because meth is as hard on the body as it is on the mind -- the relentless expenditure of energy, physical and mental, strips fat from the body, followed by muscle mass, until all that is left is skeletal.

The above photo series is entirely consistent with what I see in the ED. Actually, if anything it understates the physical devastation that meth brings. The phenomenon of "meth mouth" is amazing to see. Nobody really knows why -- whether it's a drug-related toxicity, or due to the incessant grinding of teeth, but meth users have the most astonishing dentition. 20-year olds with all their teeth broken off at the gum line. They're uninsured, practically unemployable, so no dentist will touch them, and as a result they much come to the ER repeatedly for dental pain. It's hard to blame them when you look into their mouths, but what do you do? Write weekly scripts for vicodin for people who are already addicted to one drug? Talk about a catch-22. Also, for some reason, maybe hygiene though I don't really know, but MRSA flourishes in our meth-head population. Facial lesions are common due to nervous picking at the skin, and their faces, already hollow-cheeked and sunken-eyed, become pockmarked and scabrous to boot.

I don't have a conclusion here -- there's no simple, neat, pat answer to this new epidemic. It's a scary thing, which reminds me more of the onslaught of the crack epidemic in the '80s. That seems to have peaked and I hope that out here the same can be said for meth. I see less of it than I did two years ago. But it's a scary glimpse into the dystopian future of designer drugs. Blade Runner had nothing on this stuff.

I seem to have a talent for waxing prolific about the drugs we see in the ER. I'll try to finish my trilogy with some comments on the other popular drug of abuse in our ER -- Oxycodone -- tomorrow. And if history is to be any guide, by "tomorrow" I mean "on our about May 22."

Swine Flu is the new SARS

I can testify that there were no cases of swine flu in my ER today.  I'm already sick of hearing about it.  Yes, no argument, it's a serious problem and could be awful.  The mortality rate is actually shockingly high for an influenza strain. 

I just hate hate hate the breathless hysteria of the media every single time a new "hot zone" bubbles to the surface.  Be it Bird Flu, SARS, Salmonella-flavored spinach, MRSA or what have you, it's panic first, think later.    I only wish I could program my browser to automatically mark read every article containing the word "swine."

On the advice of the Committee, the WHO Director-General decided on the following.

The Director-General has raised the level of influenza pandemic alert from the current phase 3 to phase 4.

The change to a higher phase of pandemic alert indicates that the likelihood of a pandemic has increased, but not that a pandemic is inevitable.

(h/t DemFromCT)

26 April 2009

If you're not reading Bongi, you should be

Go rectify your error.   You won't regret it.

QANTAS A380 - Panoramic

This is cool:

Click through for panoramic exterior and interior views of the A380.

It's an ugly plane -- beefy and ill-proportioned.  But it is a damned impressive plane, I cannot deny.

Via Vijay

The Express Train to Crazytown

Has anybody noticed that the loyal opposition to Our Dear Leader is, well, a little ... um ... unhinged?  And not so loyal, for that matter.

This is an interesting, and maybe a little scary, and almost unprecedented in my experience.  Clinton had a core of rabid opponents, and there were the crazy allegations about the "murder" of Vince Foster and the White House Christmas tree that was decorated with condoms, but those were fairly isolated and kind of harmless.  Most of the Clinton hate was at least theoretically sourced in flaws in Clinton's character, some of which were borne out to be correct, and the perma-investigations were purely politically calculations.   With W, there was the so-called Bush Derangement Syndrome.  On the other hand, it didn't spring into existence from January 2001 -- there was a consensus at the time that Gore's gracious concession had smoothed things over and that we had to put the election behind us.  No, the Bush derangement syndrome grew slowly over eight years from the stolen election to a war pretexted on lies, to torture, wiretapping and cartoonish levels of arrogance and incompetence. During the immediate post 9/11 time, democrats did rally around Bush to a degree that is in retrospect quite remarkable.

But now.  Wow.  We are not yet 100 days into the Obama administration, and the right is sinking to depths that previously I could never have in my wildest dreams imagined.  There was a fair degree of crazy stuff in the run-up to the election, the whole secret muslim, palling around with terrorists, birth certificate things.  I wrote that off as being due to the fervor and heightened emotions that the elections engender.  I sort of assumed that the froth would settle down over time.  But it seems to be getting worse -- crazier and more intense.  Some examples off the top of my head, which are representative but by no means inclusive of the stuff out there:

Early on Rush went on record saying that he wanted Obama to fail. I don't have a problem with that as a nuanced policy critique, which it wasn't, but it was a striking turnaround from the recent times in which anybody daring to criticise the President was tarred and feathered as unpatriotic.  More astonishing was the three or four prominent republicans who publically criticized Rush and were obliged to issue groveling apologies shortly afterwards.  Ditto to the notion that partisanship ends at the water's edge, as countless prominent republicans criticized Obama for imagined gaffes on this overseas trips.

Teabagging -- yes it's good for puerile double-entendres, and populist tax protests are a fixture every April 15.  But the "protests" were kind of surprising given that the Obama budget actually gives most people a tax cut.  It's hard to put too much weight on this, given that only like a couple hundred thousand people showed up nationwide, but it's worth a passing mention.

Michelle Bachmann expressed concerns about a "one world currency". Yeah, she's a loon in the best of times, but this comes from somewhere.  She didn't invent this slightly paranoiac concern out of thin air.

The word "socialism" has been thrown around so much in reference to Obama and his policies that it's actually lost all meaning.  It's a convenient epithet, feeds on right wing deep seated fears, and rallies the amen corner.  But again, wow.  The occasional leftie who referred to Bush as 'fascist' was generally shunned and shouted down as an unserious, divisive, deranged, unpatriotic dirty fucking hippie.  In this brave new world, it's such a pervasive topic that the first question posed by the New York Times in their first interview with Obama was, "Are you a Socialist?"  Friday, the headline in the WSJ was "RNC Chair Steele won't call Obama 'Socialist,' unpsetting some."  The some, in this case, were some RNC members and Republican members of Congress (!) who want to make the "Democrat Socialist" party the standard term of reference for the Democratic party.  This, presumably includes Rep McCarthy Bachus, who claims to have "a list" of seventeen socialists in Congress. Again, people have the right to criticize, and it's mostly theater and posturing, but isn't it amazing how this is previously extreme verbiage is finding its way into the "mainstream" of political discourse?

Speaking of fascism, that too is one of the epithets that is commonly being levied against Obama.  (I'm so old I remember when Dick Durbin was compelled to apologize on the Senate floor for an implict comparison between Gitmo and the Nazis.) If there were any justice at all, we could just invoke Godwin's Law, close the thread and declare rhetorical victory.  Glenn Beck, who really is seriously and painfully mentally ill, had a lovely bit where he warned that "they" are marching the United States towards fascism, helpfully illustrated with Nazi imagery on the screen behind him. 

This was, I think, shortly before he pretended to douse his colleague with gasoline and set him on fire.  Seriously, Glenn, get some help.

The less-favored but also present slur is "communist," which I guess lost a lot of its fear-inducing cachet since the fall of the communist regimes world-wide.

So, I get the message -- the members of the Party of Lincoln are unhappy with the direction of the country.   What's their solution?  Secession!  (Yeah, ironic, for the Part of Lincoln, I know.)  I'm sure it was just some obscure talk radio host who brought the whole thing up, though.  What?  Oh, sorry, it was the Governor of Texas.  Yeah, he was just joking, right?  Right, which is why Tom Delay took to cable teevee to explain that Texas actually can secede if they want to, and the Texas legislature is considering a resolution asserting Texas' sovereignty and instructing the federal government to "cease and desist."  I thought the whole "nullification" thing was settled along with secession back in 1865, but I guess not.  But it's just a few fringe maniacs and politicians posturing, right?  Mostly, except for the 48% of TX republicans who actually favor independence.  Maybe it's a lower number, but still, what should be an insane, fringe idea does have a surprising level of support down there.

So this is all just harmless talk, right? A little fun, slightly grandiose political theater -- don't be such a buzzkill, Shadowfax.  Let them blow off some steam, let them stamp their feet and make some noise.  That's pretty much what I thought, too, until I heard about this:

Ohio Militia Leader Calls for “Armed Million Man March” on Washington

This is a little chilling.  Yeah, I know, there's little likelihood that ten thousand, let alone a million armed militia members will march on the nation's capitol.   But in my understanding, an armed militia descending on a nation's capitol is more correctly referred to as a "rebellion," not a "protest." 

Then came Pennsylvania.  Richard Poplawski deliberately murdered three police officers with an AK-47.  He was a white supremacist, and a frequent visitor to right-wing web sites.  His motivation, according to a friend, was that he feared "the Obama gun ban that's on the way," and "didn't like our rights being infringed upon."  More recently, a Twitter user was arrested by the FBI after getting a little over-excited on the teabagging protests:
"START THE KILLING NOW! I am willing to be the FIRST DEATH!," read a
tweet at 8:01 PM that day. "After I am killed on the Capitol Steps,
like a REAL man, the rest of you will REMEMBER ME!!!," he added five
minutes later. Then: "Send the cops around. I will cut their heads off
the heads and throw the[m] on the State Capitol steps."
More disturbingly, this was in Oklahoma City.  Timothy McVeigh was also motivated by right-wing, anti-government sentiment.  And yet, the fact that the Department of Homeland Security is keeping an eye on political groups with the potential for violence somehow became an item of controversy.

Gary Kamiya writes, for Salon
Such obsessions don't come out of a vacuum. Fox News, Rush Limbaugh and the GOP have been whipping up hatred and fear of Obama and "liberal Democrats" for years. Joined by the National Rifle Association, which has run false and irresponsible ads claiming that Obama is planning to take away Americans' guns, they have encouraged and helped to create a pathological right-wing subculture in which free-floating hatred of "the government" mixes with a maniacal fetish for guns. Poplawski is the diseased fruit of that ugly tree. 

Yes, Poplawski dwelt in the most extreme part of the right wing. He is responsible for his action. You can't tar every conservative because a pathological murderer shared some of his or her core beliefs. There has been no epidemic of shootings carried out by whacked-out readers of "The Turner Diaries." [...]

With the collapse of the GOP into the party of Rush Limbaugh, and as Limbaugh and his ilk grow ever more reckless in their attacks on Obama, the boundaries between "respectable" right-wing paranoid hatred and "extreme" right-wing paranoid hatred are getting more blurred. Right-wing fanatic du jour Glenn Beck teased his recent Fox show with images of Hitler, Stalin and Lenin and said that he was wrong to say that Obama was leading America to socialism -- because Obama is actually a fascist. "They're marching us towards 1984," Beck intoned. "Big Brother, he's watching." [...]

If the demagogues on the right had any conscience, the Poplawski case would force them to realize that their shrill ravings border on incitement. But they won't. There are ratings to be maintained and a rabid base to be catered to. If every now and then some disturbed member of the base loses it, it's not their problem."
Should we be worried about this?  Is there potential for real violence?  What's the underlying cause?  Is it truly just something created and fueled by the right wing echo chamber, or are they tapping into a deeper feeling among American conservatives?  I note that Obama's approval is very high among democrats and independents, but his disapproval is just as intense among republicans -- is the extremism borne out of the severe polarization of modern politics, or is the right-wing media exacerbating the polarity and driving the craziness?

I'm honestly a little worried about this.  As I said, we're only 100 days into the Obama administration, and the intensity of the rhetoric is already over the top.  What's next?  Where is this going?  What will be the talking points in three or six years?  Can the sensible, establishment Republicans re-establish control over their party?  Can the conservative movement walk this back from the brink?

For the sake of the nation, I certainly hope so.

24 April 2009

The Big Stick

Via Jonathan Cohn at The New Republic
According to senior Capitol Hill staffers, it's a done deal: The final budget resolution will include a "reconciliation instruction" for health care. That means the Democrats can pass health care reform with just fifty votes, instead of the sixty it takes to break a filibuster.[...] The reconciliation instruction specifies a date. That date, according to one congressional staffer, is October 15. [...] Obama has apparently endorsed making paygo rules--the requirement to offset all new spending either with additional cuts or revenue--into law. I gather this was the condition Conrad, and perhaps Boyd, demanded.
Gotta interpret this as good news.  As I wrote yesterday, there are real risks and costs to actually using the reconciliation process, but having it as a threat looming over the negotiations hopefully will motivate the republicans, and their allies in the insurance and business communities to stay at the table and negotiate in good faith, rather than simply try to obstruct and preserve the status quo.

I'm not sure about the implications of making paygo statutory.  It makes it a bit tougher for the democrats to pass reform, since it demands that they have the funding in place.  On the other hand, it means it will actually be funded, which is not a bad thing! 

Exciting times.

Why retain private insurers at all?

A commenter asked a good question about healthcare market reform -- if the insurers are so inefficient/wicked/etc, why keep them around at all?

Good question, and I direct you over to Physicians for a national heal program for a rousing Amen.  What you are describing is essentially single payer. 

I've expressed it thusly: I'm a supporter of single payer the same way I'm a supported of nuclear disarmament.  Wouldn't be great if all countries got rid of their nukes?   Anyway, back in the real world...

Here are the reasons we can't just "get rid of" all those gosh-darn insurers:

1.  Political realities
There's just no Congressional support for single payer, beyond some less than influential liberal democrats in the House.  Not only are most progressives looking at market-based plans, even those more moderate plans spark fierce opposition from the conservatives, and even some squeamishness from democrats.  Influential business interests are only minimally receptive to the modest plans put forward since their interests are directly threatened by the public plan option.  It would take an absolutely seismic shift of the debate for single payer to even be given serious consideration.

2.  Public acceptance
People are ready for health care market reform, but they are also wary.  Basically, they want something to be done for all those people who are unable to get insurance, but they are mostly satisfied with their own plans and don't want to change.  They may, even dislike their insurance, but the prospect of being forced out of their known coverage to some new unknown national plan is pretty unnerving.  It's difficult to convince people that such radical change isn't very risky, and if there's no public support, the political support will evaporate.

3.  Lob losses
There are literally millions of people working in the private insurance market.  If that industry were legislated out of existence, those jobs would also be lost.  Yes, this is a short-term disruption that would in the long-run be more than made up by the efficiency of single-payer.  Especially in the current job market, tossing a couple of million people onto the unemployment rolls is not a prospect to be taken lightly.  Additionally, there are billions of dollars in shareholder equity in the private insurers that would also be lost, which would be a significant market disruption (and would not incidentally spur furious opposition from the wealthy interest threatened by single payer -- see point number one above).

4.  Monopsony
Though Single Payer has lots of internal efficiencies and ancillary benefits, it has one very big drawback.  Monopoly power allows the only seller of a service to drive up the price as high as possible.  Monopsony power is the inverse, and allows the only purchaser of a service to drive the price as low as possible.  If there was only one health insurance plan with the unilateral power to set prices, provider reimbursement would be rapidly driven down.  Given that Medicare and Medicaid already reimburse at levels that are unsustainably low, the future under single payer looks very bleak for health care providers as an industry.  Competition among multiple insurance agencies to maintain provider networks keeps reimbursement up at reasonable levels.

So much as we would love to be rid of them, the future of health care does require a role for the private insurance companies, both as matters of policy and of politics.

PA Malpractice cases drop

New rules passed in Pennsylvania in 2002 have resulted in a 41% drop in the number of malpractice filings, according to a report cited in the
WSJ Health Blog:
One of the new rules requires a “certificate of merit” from a medical professional, establishing that “the medical procedures in a case fell below applicable standards of care.”  Another rule requires cases to be filed in the county where the alleged malpractice took place — an effort to discourage so-called venue shopping, where cases would be filed in counties thought to be sympathetic to plaintiffs.
Interesting.   Though this is a pretty low bar to set -- I thought most states had certificate of merit requirements. Maybe I'm wrong.  If so, then perhaps this simple indicates that malpractice claims merely went from insanely high to the national baseline? 

Dog bites man

ER visits, costs in Mass. climb - The Boston Globe
More people are seeking care in hospital emergency rooms, and the cost of caring for ER patients has soared 17 percent over two years, despite efforts to direct patients with nonurgent problems to primary care doctors instead, according to new state data.
Hmmm.  Isn't this exactly what I wrote a few days ago? And tweeted?

ER congestion is as much due to the insured as the uninsured, and provision of universal health insurance will probably do little to alleviate the overcrowding.  In order to abate the ER crisis, there will need to be:

Either fundamental restructuring of Primary Care reimbursement to create the capacity for caring for all these low-acuity patients in the ER (which will take many years) OR a massive expansion of ERs nationwide to accommodate the volumes.

AND new rules & practices and inpatient capacity to end the practice of inpatient boarding in the ER.

23 April 2009

On Reconciliation -- an Empty Threat?

The budget reconciliation process is the legislative mechanism by which many observers expect health care market reform to be handed down.  In short, the two houses of Congress have passed Obama's budget, but as always, there are some differences between the two chambers' bills as passed.  Representatives of the two houses will meet in conference committee to work out (or reconcile, ha ha!) the differences and present a unified bill to each house for a final approval.

Now in the modern Senate, the (bipartisan) over-use of the filibuster has resulted in a condition that it effectively takes 60 votes to get anything passed.  The Democrats currently have 58 votes, at best.   So the Senate versions of bills tend to be less progressive, more centrist/conservative than the bills from the House, in which the majority has unfettered control.  The final bill that comes out of the conference committee is not subject to amendments or cloture votes, and thus, immune from the filibuster, requires only 50 votes for final passage.   It is therefore tempting to use this to shift the bill away from the agreed-upon compromise in the Senate back towards the more ideologically driven House version.

The GOP used this trick a lot in the 2000-2006 era.  Routinely, compromises made in the Senate would be stripped out in conference, and the final bill that passed would be a lot more radically conservative than the original version.  A number of fairly controversial measures were passed (or attempted to be passed) under reconciliation instructions.   I'm kind of agnostic about parliamentary maneuvers in terms of moral value, right-or-wrong, but this is a great example of "do unto others."  It might not have been such a terrible thing if the GOP had eliminated the filibuster as they threatened to back in 2005, eh?

But I digress.   So now the House version of the budget contains instructions that health care market reform legislation shall be considered under reconciliation rules.  The Senate version does not.  What will come out of committee?   Most people think it'll be a "triggered reconciliation" in which, if a compromise has not been reached by August or so under the normal order, with a bipartisan 60+ votes, then reconciliation will be invoked.

The effect here is that of a threat to recalcitrant conservatives -- come to the table and agree to a compromise bill, or we'll steamroll you and pass our version of the bill over your objections.

Now to some progressives, this is music to our ears.  Finally, after years and years of bringing knives to the gun fights, our side will play some hardball for a change.  (Forgive the mixed metaphors, please.)  We'll use reconciliation, run roughshod over our ideological enemies, and actually, finally, get the big job done without making messy concessions.  Or, the threat of reconciliation will be so effective in changing the dynamics of the debate that the special interest groups will see the realities and make the compromises necessary for a palatable bipartisan bill.  Jonathan Cohn at TNR is one such optimist.

I hate to be a buzzkill, but reconciliation has some major drawbacks.

First of all, provisions passed under the reconciliation process are time-limited in nature.  After a certain period of time, they must be re-authorized.  I think it's ten years, but it could just be five.  That's bad but not fatal.   If universal health care were enacted under this provision, and was modestly successful, then it's pretty unlikely it would be killed down the road.  You never know who's going to be in power in a decade, so it's a serious risk to take.  The GOP has never really given up on trying to kill Social Security or Medicare, and a national health care plan would probably rank even higher on their hit list.

More concerning is the so-called "Byrd Rule."

Under this provision, Senators may raise a procedural objection to any provision of a bill brought up under reconciliation.  If the Senate Parliamentarian upholds that the provision in question is extraneous to the deficit -- meaning it does not directly impact the budget, it can be stripped from the bill, unless there are sixty votes to waive the objection.

This opens up the door to all sorts of mischief for the minority.

Say they object to the clause which requires private insurance companies to issue community rated policies with guaranteed issue?   That would blow a huge functional hole in the plan and would in effect make it possible for insurers to dump all their expensive patients onto the government plan.  Or suppose the point of order was raised in respect to the universal mandate?  And on and on and on.  Yes, the bill could be crafted in a way to try to preclude such attacks.   A lot would be riding on the rulings from the Parliamentarian, and the risks are substantial.  They might not stop the bill, but could neuter it, or at least substantially degrade its value.

So I am not champing at the bit to use this process.   Perhaps this falls into the "speak softly and carry a big stick" mode of political strategizing.   The Democrats have a credible threat that they can cut off debate and pass their bill using reconciliation.   This may be effective in bringing just enough parties together to pass a bipartisan compromise bill.   Certainly a compromise bill would be the best thing for all, depending of course on exactly which compromises are made.   The threat of reconciliation, however, is one which may not be empty, but carries significant risk and material disadvantages.  If the Democrats are wise, they will not go there unless it is absolutely necessary.

Piling on

In response to Kevin's post about a missed chest x-ray finding, Buckeye Surgeon takes exceptio0n to the idea that the ordering doctor is responsible for following up the findings:
Do we really believe that some urologist is going to be the one who coordinates the appropriate follow up for an abnormal chest X-ray? A urologist? God help us all if that's the honest solution.

As a surgeon, I send all my elective patients for pre-operative testing. This usually involves some combination of blood work, an EKG, and sometimes a chest X-ray. The determination of what is needed is often left up to the pre-testing center, the primary care doctor, and the anesthesiologists who will be doing the case. On the day of the surgery I glance through the chart, make sure everything is copacetic, and then we proceed. Sometimes the lab will call a few days prior to surgery with an abnormal value and I will look into it dutifully. I'll be honest; I don't pay much attention to a CXR report unless I'm specifically concerned about something beforehand.
I hate to say it, since I respect ol' Buckeye, but I'm with Kevin on this: you order the test, you own the results.

I deal with this all the time in the ER, and it's as annoying there as it is anywhere else.  I get the CT chest to rule out a PE, or the CT head for a blunt head injury, and it comes back negative.

Negative, except for some little incidental finding that's probably nothing, may be something benign, or very unlikely may be cancer or something bad.  Now I don't really care about this distl: it's not related to the reason I ordered the test, it certainly doesn't impact my care for the patient, and I am certainly not going to follow it up myself.  So what do I do?

For me, I've got the patient in front of me.  So I tell the patient.  That's always a fun conversation -- your chest x-ray was fine, but you might have cancer, and you should have your regular doctor check it out! I'm more diplomatic that that by a lot, but that's what patients hear, no matter how delicately I phrase it.   You can imagine how quickly their anxiety-mediated chest pain comes back after that conversation!

Seriously, though, that's the obligation that comes with the territory.  It's silly to expect the radiologist to inform the patient they have never seen or spoken to, just as the pathologist doesn't call the patient with their pathology results.   I also document my conversation with the patient, write the results down on their discharge instructions, and, if it's worrisome at all, I send a note or a voice mail to the PCP so it doesn't get lost.

I can see why it would be harder for a surgeon, since the patient may not be around when they get the results, and that may be well before or after the procedure.  Still, they have it easier since nearly all of their patients have a referring doctor or a primary care doctor that you can turf the work-up to.  How hard is it to send an email, fax, voice mail, or dictation?  Or to make a note in the chart and tell your secretary to make sure a letter is sent?  Lots of options there.

It's a pain in the ass to do stuff right, and it's really tempting to cut corners.  I get it.  But still: you order the test, you own the result.

Incoherent opposition to the public plan

The real fight in the Senate over healthcare market reform is whether a "public plan" will be included.

Put simply, a public plan would be something akin to Medicare -- a government-administered insurance plan that consumers could choose to purchase if they were unable to buy private insurance, or perhaps even if they preferred the public plan over the private insurance products available.

It's important to know that this is not a new concept.  In fact, similar plans exist today in many states -- with some key differences.  Mostly, the state-run plans are designated "high-risk" insurance pools and are restricted to individuals who have been rejected or are unable to find insurance in the open market, usually due to pre-existing conditions.   This "adverse selection" ensures that only the sicker, more expensive patients enroll in this plan, which results in the plan premiums being much much higher than is typical in group insurance products.  Ironically, the consequence is that most individuals who need the insurance are therefore unable to afford it, and the state plans usually wind up terribly underutilized.

The public plan in the proposed market reforms differs only in terms of the overall insurance environment.   Since insurers, hypothetically, would be required to charge all applicants the same price (which is called "community rating") and they would not be allowed to reject people with pre-existing conditions ("guaranteed issue"), the higher-risk individuals ought to be able to find affordable insurance from a variety of sources, private or public.   The absence of adverse selection should ensure that the public plan is no more expensive than the private products available.

At least, in theory.  There are a large number of people, myself included, who are skeptical that the public plan will not suffer from adverse selection.  Insurers have a great motive to select only the healthiest, most profitable patients to cover.  Currently, they are able to do so easily and directly: reject those with pre-existing conditions.   Under guaranteed issue and community rating, they will have to be creative in finding ways to get the young and healthy to choose their plans, but I do not doubt that they will do so to some degree.  The consequence of this is that the public plan should eventually become loaded with sicker patients and burdened by higher premiums.  this would produce a self-reinforcing cycle as patients fled the public plan to cheaper private plans.  Eventually, it would wind up like the small, expensive, and underutilized state high risk pools.

The other possibility is that the public plan will have some advantages due to lower overhead, executive compensation, provider networking, lack of profit motive, etc, which will lead to the public plan being cheaper, and thus patients would prefer the public plan and shun the private insurers.

This is the possibilty which strikes fear into the hearts of the insurance lobby and their allies on the Hill.   Republican leadership has opposed this public plan, citing that it would "create an unlevel playing field and inevitably doom true competition. [...] Ultimately, we would be left with a single government-run program controlling all of the market. This would take health care decisions out of doctors and patients and place them in the hands of another Washington bureaucracy.”  Just today there was an article in Modern Healthcare citing the opposition of Blue Cross/Blue Shield to the public plan: "innovations would be impossible if they had to compete with a government-run plan."

The premise of this opposition is, however, based on some self-contradictory logic, and on an assumption that the public plan will have Medicare reimbursement rates.   If the goverment-run plan turns out to be an NHS-style nightmare of byzantine rules, rationing care, and bureaucratic interference in the doctor-patient relationship, wy would patients choose it?   Seems to me that the marvels of competition would ensure that patients would shun such a system and flock to the consumer-oriented private insurance plans. 

Even if the public plan is somewhat cheaper, consumers who have the ability to make free choices will pay more for access, for free choice, and for services.  If a government-run plan is something as terrible as conservatives take as an article of faith it will be, then it should not represent a competitive threat to the private insurance industry.

The nice thing about the public plan option is that it is just that, an option.  Consumers will be free to choose.  If it turns out to be better, then that will force the private insurers to improve their service, improve their quality, to innovate in health care management -- or die.   According to the BC/BS CEO, the private market has always been more innovative than the government.  Great!  If so, then the competive pressure applied by a public plan will spur that innovation that will help all of us.  It's a grand experiment, and we'll pit the two against one another an see who wins -- or, more likely, how they settle into a relationship of dynamc tension, neither prevailing, but co-existing.

It's unfortunate that the right seems to be digging in their heels over this, because there is a point of negotiation which might get lost.   If they simply refuse, and force the democrats to ride roughshod over their objections, it is likely that the left wing will create a public plan that does have inherent advantages over the private sector.  Namely, it will either use Medicare reimbursement rates or will have the authority to unilaterally set rates.   If the GOP came to the table as good-faith bargaining partners, they could agree to the public plan's inclusion with the contingency that it have no power to drive down the rates, but have to compete on fair terms with other insurers.  But their brinksmanship, all-or-nothing approach threatens to miss the opportunity to craft the public plan in a way that would be advantageous to all stakeholders.

And that's the real down-side to the Republican party putting ideological purity ahead of pragmatic governing.

Make me do it

There's an apocryphal story about FDR's approach to his progressive allies shortly after his election:
A group came to him urging specific actions in support of a cause in which they deeply believed. He replied: "I agree with you, I want to do it, now make me do it."

He understood that a President does not rule by fiat and unilateral commands to a nation. He must build the political support that makes his decisions acceptable to our countrymen.
In this vein I was very happy today to see this story in the WaPo:

Health-Care Dialogue Alarms Obama's Allies
More than 70 House Democrats recently warned party leaders that they will not support a broad health reform bill that does not offer consumers a government-sponsored policy, and two unions withdrew from a high-profile health coalition because it would not endorse a public plan.
This is the right way for the left wing to proceed.  Be involved, negotiate and be open to discussion.  Pick the points that are priorities.  And make sure the President, and the political world know there is a point at which you will walk away.  Obama wants a public option -- so do Waxman and Kennedy.  If the bill is held hostage by Evan Bayh and Olympia Snowe, it would be easy for the negotiators to toss it out as a bargaining chip, as Max Baucus has indicated he is willing to do.  But if there is a credible way in which the leadership can say: "this is essential -- my people won't agree to any package without it," then it no longer is in jeapordy as a token. 

Cheerleading will only get you so far.   The gravitational center of the political world is the center.  Progressive agitation is the way to create a countervailing force which will make it possible for Obama to demand the deal he actually wants.

22 April 2009

Home at last

Will get a round-up of the trip tomorrow, for now, enjoy this picture of lenticular clouds over Mount Ranier, taken from my plane window on Sunday.

20 April 2009

Crisis in the ER

Our ER is working well in recent months, but being here at the Leadership conference is a striking reminder of how challenged our system is, nationwide. The boarding and overcrowding crisis has not abated for my colleagues in other facilities and other regions, and I am hearing that loud and clear from the other physicians and medical directors in attendance.

So why are ERs so damn overcrowded, anyway?

Turns out that there are a lot of interrelated reasons.  Simple demographics plays a role, of course.  This point has been made in spades before, but to recap: there are more Americans than there were 20 years ago, but there are fewer acute care hospitals and fewer ERs to serve them.  Additionally, there are people living longer with more chronic diseases.

The corollary to fewer acute care hospitals is that there are fewer inpatient hospital beds.  This trend started in the '90s when it was generally agreed that there was an oversupply of hospital beds, and that managed care would drastically reduce the utilization of inpatient capacity.  The result was that the industry went through a wave of consolidation and downsizing.  This may have made good policy sense at the time -- I don't really know -- but it certainly made good economic sense for hospitals.  Like an airline that doesn't want to fly with empty seats, hospitals don't like to operate with empty beds -- it's wasted overhead, and more efficient if you can cut the marginal capacity and operate close to full all the time.  Only problem was that this leaves precious little margin for surge capacity come flu season, and little room for population growth.

The lack of inpatient beds led to inpatients boarding in the ER.  There was just today a nice article in Annals of Emergency Medicine which purported to show that Admitted Patient Boarding Times have a more significant contribution to ED congestion than physical plant size (number of beds).  

Boarding is probably the most significant contributor to congestion in most facilities, but it's not the only.  One insight I drew today from the talk about the Massachutsetts MA universal health plan was that the slow death of primary care is also in large part to blame for the continuing deluge of patients to the ED.

The MA experience was interesting in that there were 600,000 uninsured in that state prior to the reform, about 500,000 of whom ultimately wound up getting health care coverage as a result.  The data shows, however, that ED utilization did not decrease as a result, and in fact, it continued to increase at a pace beyond that of population growth.  Why is this the case?

First, as many have pointed out, there are simply not enough idle primary care physicians out there to absorb all these newly insured patients into their practice.  The hope had been that patients would gain access to primary care services and that this might decrease demand for ER services, but that was not to be the case.   (Given the dearth of medical students intending to enter primary care, do not expect that situation to improve.) 

But when you look back at some of the other data published, the larger point rings through -- that ER congestion is as much due to the insured as the uninsured, and provision of universal health insurance will probably do little to alleviate the overcrowding.  

Non-urgent use of the ED also does not seem to be a large driver of congestion.  Understand, though, that non-urgent patients and low-acuity patients are not one and the same.   A broken ankle, a sore throat, or a laceration are all low-acuity.   They are also urgent, at least in the eyes of a patient who is unable to walk, in pain, bleeding, et cetera.  And the truth is that the ER is better at treating these acute presentations than physician's offices are.

Not better in the sense of skill or quality, better from the patient's perspective of their time and convenience.   We are open 24/7, and for places with functional fast tracks it's possible to be in and out in under an hour.  Even for patients with slightly more complex problems - vomiting or abdominal pain -- two to four hours is the median range of their LOS.   This is awesome from a patient's point of view, compared to trying to get cared for in the office of your primary care doctor.   (Which assumes that you even have one.)

It's challenging to get in for an acute appointment, assuming that same-day appointments are avilable at all: you have to wait for office hours, call in, try to get the nurse, and hope to convince them that you are sick enough to be seen that day.  You may see your doctor, or you may see a doctor you don't know.  Then you have to wait for your appointment time, and if any ancillary tests are needed, you may have to go over to the lab, to x-ray, etc.  Often you then go home and wait for the doctor to call with the results.  It's an all-day experience, frustrating and a hassle.  This is in spite of the fact that many PCPs want to see the acute cases.  The low reimbursement for office-based practice forces them to schedule their clinic so tightly that patient convenience is not something easily accomodated, and certainly not in any large quantity.

So it's no wonder that consumers of health care, being rational actors, preferentially elect the more convenient avenue of care.   And two very necessary and very well-purposed pieces of legislation conspire to encourage patients to pursue this quick but very expensive option: EMTALA and Prudent Layperson.   Since EMTALA was passed, most ERs simply gave up trying to screen or redirect patients away from the front door, believing it illegal.  Those that try run terrible PR and legal risks.  So we have accepted the burden of the low-acuity urgent cases, built fast tracks, and tried very hard to make the care for these patients as quick as possible.  In part, this was intended to allow more resources to be focused on the more seriously ill, and in part this was due to the fact that fast tracks turned out to be nice profit centers.   By making ER care faster, quicker, and easier, we have further incentivized patients to eschew the clinic and just come on down.

Similarly, the Prudent Layperson rules have had the same effect.  Prudent layperson was a completely appropriate response to the bad behavior of insurers, just as EMTALA was a necessary response to bad behavior on the part of providers.  Both serve to remove any disincentive to come to the ER for minor conditions.  If the payer could require pre-authorization or credibly threaten to refuse payment, then patients would be more likely to choose a more cost-effective care setting.  But since this is now all but forbidden, patients have carte blanche to utilize the ER as a convenience clinic.

I'm not sure this is all bad, by the way.   If boarding went away as an issue, it's entirely possible that ERs might be able to accomodate the volumes, and despite the expense they incur, the ER does a lot very quickly and efficiently.  If the proposed medicare rules for Type B EDs go into effect, then fast tracks will be a much more cost-effective site for urgent care.  This also frees up the internal medicine physicians to manage complex and chronic conditions, which is ultimately their core competency.  Perhaps this is the future - Emergency Medicine blends into an over-arching Acute Care Medicine specialty.   It might not be the way an ideal system would have been designed, but it looks like that is where we are going, and I don't see any way to put that genie back into the bottle.

My Big DC Trip

I'm in DC at the ACEP Leadership & Advocacy conference.   Basically health wonk/politics junkie heaven.   I'm intermittently twittering the speakers (when I have a wireless signal, which is damnably infrequent).  You can follow my twitter feed here, for what it's worth.

The ACEP staff, god love 'em, are trying to get "with it" and maybe even "go viral."  So you can follow their twitter feed here, and a proto-blog called The Central Line -- good name, let's hope they get more content up.  Maybe I can trick them into giving me access!

The biggest frustration about the DC meetings is that they always schedule luminaries to come speak, and the officials often do not show.  I know, they're busy people doing real work and I don't resent the fact that we are low on their priority list.  But we were supposed to hear Pete Stark talk about the prospects on reform from the Congressional perspective -- now like him or hate him, Stark is a real player, and health care has been his deal for a long time.   So I was pretty bummed that he cancelled.   The replacement speaker, Roy Ramthun, gave a good "inside baseball" outline on the prospects for reform, but without the star power. 

Then our lunch speaker, Office of Health Reform Director Deparle also was unable to attend, sending one of her deputies instead.  The messaging could have been better, unfortunately, as she almost immedately alienated a friendly audience with a "things are pretty good - over 80% of your patients are insured" lede, and followed that with the "if only we could get all those non-urgent patients out of your ER, things would be great," myth.  To an audience steeped in the boarding and crowding crisis and very invested in addressing the uninsured/EMTALA problems, this was not a recipe for building goodwill.  She talked a lot about expanding access to care, especially primary care -- fair and good -- but when asked about the specific issues addressing acute care medicine, there was a lot of tap-dancing and punting.

I agree that primary care is an urgent problem, but there are also huge problems in the emergency care safety net, and it was disappointing that the OHCR staffer couldn't be bothered to brief herself on them before coming to a conference of ER docs.

The best talk so far was a joint presentation by odd couple Ron Pollack of Familes USA, a health reform advocacy organization and Bruce Josten of the pro-business Chamber of Commerce, both of whom have been involved in Kennedy's so-called Workhorse group.   There was a lot of stuff about the mechanics of organizing and mobilizing your activist base.  Interestingly, the Chamber's methodology is a very top-down structure which nobody can deny is an effective model, but he kept calling it a "grassroots" model, motivating my neighbor to lean over to me and quip, "He keeps using that word. I do not think it means what he thinks it means."  It was also interesting to hear the areas of agreement these two very disparate groups have found on the need for and specifics of health care reform.  

Well, I'm off to an afternoon session now -- more when I get a chance...

16 April 2009

Odd Tooth Fairy Tradition

Vijay said the same thing in the comments the other day.   I assumed he was just screwing with me.  Not that I'm using the "Baby Blues" comic as an authoritative reference or anything, but now I'm starting to wonder if he was on the up and up.

Unless maybe he read the comic first and was using it as a basis for screwing with me...

Health News of the Week

The Uninsured

The Chicago Tribune continues its excellent series on patient dumping in Chicago:
Are hospitals passing off their low-profit patients?
Indigent and under-insured patients are turning to Cook County's Stroger Hospital after not getting fully treated at non-profit hospitals, swamping the cash-strapped public facility while fueling the county's sky-high sales tax.
Which raises the fair question of whether not-for-profit hospitals have an obligation to actually provide charity care -- and how much? -- in order to qualify for their tax-advantaged status.

Medical Inflation

Slate's Timothy Noah writes:
Even before the bottom fell out of the economy, almost nobody in the United States got a real raise during the Bush years. Between 1999 and 2008, employer-sponsored health insurance premiums increased six times faster than wages. Average employer contributions to family health care plans more than doubled, and so did average worker contributions to those plans. Whatever pay increases the average worker received were wiped out, and then some, by the rapidly growing amounts deducted from his paycheck to cover health insurance.
Maggie Mahar points out that Medicare itself has been hit by the increasing cost of healthcare, and differs from most insurers in that there is no cap on the amount beneficiaries have to pay out of pocket:
in just the past seven years, the amount a retired couple can expect to lay out in the form of co-pays, deductibles, out-of-pocket costs for prescription drugs, as well has certain services not covered by Medicare has jumped 50 percent, from $160,000 to $240,000.
Ezra dissects a study by the nonpartisan McKinsey group to explain why American health care is so much more expensive than everywhere else in the world:
McKinsey estimates that the difference is not sicker Americans. Differences in diseases account for only $25 billion of the variation -- about 5 percent of the total. Nor is it that we use more health care services. McKinsey examined inpatient hospital procedures to get a sense of how treatment volume compares. America averaged 88 procedures per 1,000 residents per year. That's higher than the OECD average of 75, but it's not as high as Germany's 97 treatments per 1,000 residents, or Switzerland's 98 treatments per 1,000 residents, and both countries spend much less on health care than the United States.

The answer, in the end, is that we're getting a bad deal. You know how when you go shopping you look for sales? America sort of does the opposite of that. We pay more for each unit of care, more for health system operations, and more for health system administration. McKinsey found that "input costs—including doctors’ and nurses’ salaries, drugs, devices, and other medical supplies, and the profits of private participants in the system—explain the largest portion of high additional spending, accounting for $281 billion of spending above US ESAW. Inefficiencies and complexity in the system’s operational processes and structure account for the second largest spend above ESAW of $147 billion. Finally, administration, regulation, and intermediation of the system cost another $98 billion in additional spending."
The Wonk Room recaps both sides of the debate on whether innovations in health IT, organizational quality, and comparative effectiveness research will actually do much, if anything, to constrain the growth in costs.   For my part, I hope so, but color me skeptical.

Insurers behaving badly

The NYT writes about the unanticipated side effect of oral chemotherapies -- Insurance often doesn't cover it:
Chuck Stauffer’s insurance covered the surgery to remove his brain tumor. It covered his brain scans. And it would have paid fully for tens of thousands of dollars of intravenous chemotherapy at a doctor’s office or hospital. But his insurance covered hardly any of the cost of the cancer pills the doctor prescribed for him to take at home. Mr. Stauffer, a 62-year-old Oregon farmer, had to pay $5,500 for the first 42-day supply of the drug, Temodar, and $1,700 a month after that.
The WSJ Op-ed page argues that white is black, war is peace, and the wasteful administrative costs of private health insurance is "money well spent."

Andrew Sullivan links to a trenchant observation about the role of insurers in our system:
The simple truth is that one of the major reasons we have such a lousy health care system and receive such bad value for our money in the US is that we placed health care financing into the hands of the same folks who helped make our economic system such a disaster: private insurance companies, who are little more than disguised investment banks with the added incentive not to pay back their depositors (the premium payers).
The same insurance industry, according to Media Matters, which is employing Newt Gingrich as its stealth lobbyist:
According to the Center for Health Transformation's website, members pay tiered annual membership fees, providing varying degrees of "[a]ccess to Newt Gingrich on your company's strategy," among other benefits. Insurance groups UnitedHealth Group, the parent of UnitedHealthcare, and WellPoint Inc. are listed as "Charter" members.
Nothing wrong with that, though when Newt goes on teevee to talk about reform, it somehow never gets mentioned that his bread is buttered by the industry that he is covering.

Health Reform

Conservative Ramesh Ponnuru argues in a NYT Op-Ed that the quest for Universal Coverage is "Misguided," and offers a conservative alternative plan.  To my eye, it looks pretty identical to the one McCain proposed prior to the election; Ezra rebuts that the plan, authored by the conservative Galen Institute, is just covert rationing. (Hmm, where have I heard that phrase before?)   The Wonk Room goes further, detailing why free market principles will not work in the distorted and broken market that is health care:
1. Monopoly — occurs if a single buyer or seller can exert significant influence over prices or output: In health care, “insurer and hospital markets are increasingly dominated by large insurers and provider systems.” “The increased concentration has made it difficult for the nation to reap the benefits usually associated with competitive markets.”

2. Negative Externalities — occur if the market does not take into account the impact of an economic activity on outsiders: In the ‘wild west’ environment of the individual health market place, companies leave the sickest patients without coverage. Health care costs increase for everyone when patients are forced to forgo early and appropriate care or visit the emergency room once a condition becomes unbearable.

3. Asymmetric Information — occurs when one party has more or better information than the other party: Americans looking for coverage in the individual market have no way of comparing different policies or rarely know what the plans actually cover.

Conservative health proposals double-down on this broken marketplace.
Joe Paduda argues, extrapolating from a Commonwealth Fund Study, that
In several areas the US already has longer waiting times and poorer access to care than countries with universal healthcare. If the US adopts universal healthcare as practiced in other countries, the evidence indicates access will go up and waiting times may well go down.
Joe also writes a stinging post about the myth that government just can't do anything right:
It would take a good deal of hard work to be more incompetent than some of the health plans out there today.
Some resurgence in interest in the little bipartisan reform that could -- Wyden's Healthy Americans Act.  Is it too late?

Last week, the Public Plan option was much in the news.  The NYT editorial page wrote:
A new public plan is neither the cornerstone of health care reform nor the death knell of private insurance. It should be tried as one element of comprehensive reform. If, over time, a vast majority decides the government plan is superior, so be it.
There have been some concerns that it might be dropped as a political token, in order to achieve passage of the rest of the reform package, but Nancy DeParle, Obama's Health Reform Czar, asserted that the administration is still behind the public plan as an element of health reform, and offered some insight to the options under consideration:
A public plan is something that’s sponsored by the government, and therefore has very low or almost nonexistent administrative costs, compared to others. It doesn’t have the need to have brokers out selling; it wouldn’t have the need to have a lot of costs and profits, the way private plans would. So it has that advantage. It could operate
by the same rules that all the other plans do; it could have payments rates that are very similar. Or it could have payment rates that are the same as Medicare.
As you can see, there are some rather significant distinctions between the public plans described.  Johnathan Cohn at TNR's The Treatment explains:
One is what you might call the full, or strong, public plan option: Creating a new insurance program that the government would run directly, much as it does Medicare. The idea would be to take advantage of Medicare's efficiencies as well as government's ability to set lower reimbursement prices. Projections suggest that such a program would have the potential to offer substantially lower premiums. [...]

Of course, precisely because a strong public plan has the power to offer lower premiums, the idea is a non-starter with the insurance industry. Since it would achieve a lot of its savings by reducing reimbursement levels, it's not exacty popular with the providers of medical care. And because it is, by definition, "government run," it's anathema to most conservatives.

That's why a second version has emerged, which you might call the partial, or weaker, public plan option: Creating a plan, or set of plans, that realize some of the administrative savings you find in programs like Medicare but explicitly avoid using government bargaining power to set prices. These plans would have potential to achieve some savings, but not nearly as much; and it's not clear whether they'd be as secure, or offer the same protection to the truly sick (who rightly worry whether private carriers will take care of them), as a strong public plan.
As a provider, knowing that Medicare reimbursements are already unsustainably low, I favor the second model.  It would compete on a more level playing field with the privates, and would do less to further depress reimbursement rates.