29 May 2009

I want to stand and stare again

Saw this one live. Memories.

I've been fighting off a killer flu (no, not that flu!) along with the rest of the family. Slowly am re-entering the land of the living. Anticipate a return to semi-regular posting next week.

21 May 2009

The Best Thing I've read today.

The ER Doc Pain Scale « Ten out of Ten
3.38: Pelvic Exams
-If I had known how many of these I’d be stuck doing, I probably would have gone into anesthesia

3.40: Speculum light lost/doesn’t work
-Nurse get the crazy-looking bendy-armed light out and look into how long an anesthesia residency is

Most under-rated:
1.79: Patient brought back from xray, never hooked back up to the monitor
-Meh, it’s just a bunch of squiggly lines and numbers

Trust me, I know from personal experience this is more than a 1.79/10.

20 May 2009

In which I shall agree with Scalpel

I'll pause a moment for you to wipe the coffee off your monitors.

Yesterday, Scalpel and ERP tackled an interesting question: What is an ER?
[whether] it is our duty as emergency physicians to see every patient that presents for care whether they have the inclination or ability to pay us or not, and if we do not treat all comers then we are not practicing Emergency Medicine.
and Scalpel lauded the concept of the boutique freestanding ER, which accepts cash and private insurance but not government insurance, thereby evading the obligation to provide EMTALA-mandated services to all comers.  ERP was concerned about the implications of this sort of practice with specific reference to whether this violates a core principle of emergency medicine -- the mission to care for all patients first and worry about money later.

Strangely, I don't have a moral problem with the boutique practices.  You'd think, being such a bleeding heart lefty that I'd be reflexively bitching about the poor and vulnerable who are denied care at these boutique practices.  I'll admit that it's a troubling thought, but the local community, county and academic ERs are already the dumping grounds for the clinics, urgent cares, nursing homes, and anybody else that wants to get unburdened by troublesome patients.  So the boutiques don't change that one iota, and could even improve access by decompressing those existing ERs.

Moreover, I don't buy the notion that a defining characteristic of being an ER doc is an abandonment of financial interest in your work.  Just because you have the letters FACEP after your name doesn't mean that you have entered holy orders or taken a vow of charity and poverty.  I take a very entreprenurial approach to running our practice and I have nothing but admiration for those ER docs who have thought creatively and taken a risk in setting out on a new course.

But (and you just knew there had to be a "but," right?) there are some serious drawbacks of these boutique ERs, from a systems perspective.

My biggest concern regarding their existence, were they to become more common, is that they skim the profitable business off of traditional ERs and thereby weaken their parent institutions.  The same argument, by the way, applies to outpatient surgical centers and other outlets which remove profit centers from hospitals.   While such projects make great financial sense for their owners and for their physicians (often one and the same), the overall effect is quite destructive on the system.  Hospitals are required to provide many many services at a loss -- inpatient medicinal services prominently among them.  They have no choice in that.  They also have to provide care to the uncompensated and the under-compensated.  The entire economic basis for a hospital is frantic cost-shifting from profit centers to loss centers in a hopes of eking out a 3% margin at the end of the year.  The grim fact of hospital closures and the national shortage of inpatient beds is due to this incredibly tenuous business model hospitals exist within.  (The lack of inpatient beds, BTW, is largely reponsible for the ER boarding and crowding crisis.)

To the degree that boutique ERs could make the hospitals' fiscal problems worse, I'm glad that they are unlikely to become widespread.  In fact, I predict that they will either completely cease to exist or will be only a very small niche within healthcare.  

One big obstacle to boutique ERs is the requirement that the docs opt out of Medicare.  This is a huge and scary step for most docs and will ensure that only the most committed few take the plunge.  Remember, you can't reapply to medicare for two full years once you opt out, so if the venture fails, you're unemployable as an ER doc for two years.  That risk, I think, will cause many ER docs to shy away from a boutique practice.  (The alternative, BTW, is for docs to remain in the medicare program and just turn all seniors away from the door of their boutique ER.  Good luck with that business model!)

State regulations pose real obstacles to these practices as well.  In California and other states where balance billing is not permitted, this sort of practice is essentially impossible, since you can't bill a patient for anything above what an insurer is willing to pay (which includes medicare).  As balance billing legislation becomes more widespread (and it will), this will progressively narrow the playing field on which boutique practices can even compete.   The willingness of insurers to pay ER billing codes for non-EMTALA-compliant ERs will also vary greatly by state, and by the degree of clout that insurers have in each state.  If these practices became more common, the insurers would logically respond by creating edits in their software that would transform ED site of service codes into ambulatory codes.

Another obstacle which is not insignificant is that the capital requirements for a fully functional ER is not insignificant.  A "real" ER is going to need, at a minimum, a CT scanner, a radiology suite, an ultrasound tech, and a stat lab in addition to the physical plant and ancillary staff.  That money is tough to raise unless you have the backing of an institution.  It's possible to make an ER on the cheap, but I would contend that as you scale down the ancillary services offered, the difference between an ER and urgent care center becomes fuzzier and fuzzer.  To the degree that there will exist a market for emergency services and funded patients to utilize them, it's more likely that hospitals will create EMTALA-participating free-standing ERs to fill that niche.

So ultimately I have a hard time getting too exercised about the boutique ER practices.  They pose a theoretical threat to the fabric of the safety net, but there are just too many barriers and pitfalls for them to become widespread players in the acute care field, even assuming that they don't get legislated out of existence by reactional lawmakers or regulators.

19 May 2009

Kennedy in remission

TheHill.com - Kennedy's cancer in remission
Sen. Edward Kennedy’s brain cancer is in remission and he is expected back in the Senate after the Memorial Day recess to spearhead healthcare reform, according to Democratic colleagues.

Senate Majority Leader Harry Reid (D-Nev.) said Tuesday that he spoke with Kennedy’s wife, Vicki, in the past few days and was told the 77-year-old lawmaker is “doing fine.”

Reid said Kennedy’s cancer is in remission and added that while the lawmaker is going through another regiment of treatment, the procedure “is not unusual.”

Kennedy, the chairman of the Senate Health, Education, Labor and Pensions (HELP) Committee, has been mostly absent from the chamber for the past year, recovering in Florida and Massachusetts.

He is expected to lead a markup of highly anticipated health reform legislation in his first month back - one of the biggest bills of the year and a signature domestic initiative for President Obama.
Well, this is great news.  It's not cured -- if he has a malignant glioma there's not going to be a cure.   But that he is well enough to be back at work is awesome for him personally, and that he will be back in time to help shepherd his signature issue through mark-up and hopefully passage is great for advocates for reform.  It's been a year to the day since his diagnosis -- the one-year survival is only about 50%.   The two-year survival is only about 8%.  That's a bad disease.  So I for one am grateful that he's well enough to be back at work for one last push.  Talk about leaving it all on the field.

17 May 2009


Dropkick murphys once more

16 May 2009


I panicked.

15 May 2009

More on Orzag

Well, this didn't take long:

Health Care Leaders Say Obama Overstated Their Promise to Control Costs
Hospitals and insurance companies said Thursday that President Obama had substantially overstated their promise earlier this week to reduce the growth of health spending.

Mr. Obama invited health industry leaders to the White House on Monday to trumpet their cost-control commitments. But three days later, confusion swirled in Washington as the companies’ trade associations raced to tamp down angst among members around the country.
Well you can just knock me down with a feather that the industry leaders are frantically trying to walk back their pledges, though I certainly am surprised to see it so quickly.  Interestingly, uber-nerd OMB Director Peter Orzag writes on his blog (of course he has a blog!) that it's really not as big a deal as the NYTimes makes it sound:

OMB - Blog Post - Misdiagnosis
A media report this morning makes a mountain out of a molehill – suggesting that the commitment earlier this week by health care providers and insurers to reduce cost growth was overstated. Here is what the groups stated in a letter they signed: "we will do our part to achieve your Administration’s goal of decreasing by 1.5 percentage points the annual health care spending growth rate—saving $2 trillion or more." The groups have since clarified that they may need to "ramp up" to the 1.5 percentage point reduction in the growth rate, which is understandable.
Frankly, the whole kerfuffle seems a little silly to me, bickering about the exact rate of reduction in expenses in a pledge made by multiple entities with no accountability or enforcement.   Happy talk and fluff is tough to quantify, which is difficult to reconcile with the exactitude that the Budgeteers bring to this sort of endeavor.

Today's must-reads

In an unsual Wall Street Journal op-ed, White House OMB director and nerd celebrity Peter Orzag continues to push the point he's been making for the last several years: Health Costs Are the Real Deficit Threat
[H]ealth-care costs drive our long-term entitlement problem. An example illustrates the point: If costs per enrollee in Medicare and Medicaid grow at the same rate over the next four decades as they have over the past four, those two programs will increase from 5% of GDP today to 20% by 2050. Despite the attention often paid to Social Security, spending on that program rises much more modestly -- from 5% to 6% of GDP -- over the same time period. Over the long run, the deficit impact of every other fiscal policy variable is swamped by the impact of health-care costs. [...]

Health-care costs are already so high and the power of compound interest so strong that reducing the growth rate by 1.5 percentage points per year would save substantial sums. It would reduce national health expenditures by more than $2 trillion over the next decade. [...] A slower growth rate in overall health-care spending would help to promote and sustain a slowdown in Medicare and Medicaid spending, too. If cost growth slowed by that much in the future, Medicare and Medicaid spending would reach only about 10% of GDP by 2050 -- half the level than if historical growth rates continued.
This is followed by an earnest but optimistic exposition on four steps to restrain spending: HIT, CER, Prevention, and reimbursement reform to "reward quality."  All laudable and beneficial goals, and perhaps they will have some marginal benefit in constraining the growth in costs.

But for once, I have to agree with David Brooks of the NYT: Fiscal Suicide Ahead
There are deep structural forces, both in Medicare and the private insurance market, that have driven the explosion in health costs. It is nearly impossible to put together a majority coalition for a bill that challenges those essential structures. Therefore, the leading proposals on Capitol Hill do not directly address the structural problems. They are a collection of worthy but speculative ideas designed to possibly mitigate their effects.

The likely outcome of this year’s health care push is that we will get a medium-size bill that expands coverage to some groups but does relatively little to control costs. In normal conditions, that would be a legislative achievement.
The rest of Brooks' column is off-base, in that Obama's deficit spending is otherwise disconnected from health care.  I'm still an enthusiast for the health insurance reform plan, if only because of the necessity of covering the uninsured.   We should not, however, delude ourselves into thinking that it will solve all our problems, and some of them, cost growth in particular, will be exacerbated by the expansion of health insurance, requiring further reforms down the road.  I'm OK with that -- politics is the art of the possible, and I don't think that universal coverage and definitive finance reform are possible in the same year.  Nothing in what I've seen thus far makes me think that much inroads into cost containment will be made this cycle.

13 May 2009

Newsy Bites of the Day

Congress Matters ::
Congressional leaders are looking at accelerating the schedule on health care reform legislation.   Why?
Should the House meet its July 31 deadline, Senate Republicans would be under intense pressure to vote for a negotiated health care compromise or see Senate Democrats tackle the overhaul under the budget reconciliation instructions that would make it immune to filibuster in the Senate.
This is good.  The House bill will almost certainly have some version of the public plan.  The Senate debate will take place with that fact established, which may, we hope, embolden moderate Dems into holding out for a fair public option.

Speaking of moderates:

Ben Nelson All Alone In Quest To Block Health Care Reform
Sen. Ben Nelson announced at the beginning of this month that he opposed the creation of a public health care plan that people would have the option to buy into. He'd be gathering together a coalition of like-minded senators to oppose the plan, the conservative Democrat from Nebraska promised.

More than two weeks later, it's still a coalition of one.
Good.   As supporters of real reform are rallying, moderates are wary of being left out of the process.   Moreover, they'd rather be on the winning team than take the risk of trying to broker an unpopular compromise that might not even be necessary.  Open Left now reports that there are 51 Senators open to the possibility of a public option.

Open Left:: 51 Senators Open To Public Option
It now seems likely that there are enough Senators in support of a public health care option to pass it through the 50-vote reconciliation process.
Soaring Costs, Not Universal Coverage, Drive Health-Care Debate - TIME
In 2009, after much of the rhetoric on last year's campaign trail focused on the growing ranks of the uninsured, the major thrust of health-care reform centers on something that affects everyone: the staggering cost of a system that threatens to devour the rest of the economy.
Karen Tumulty points out that the need to greatly expanded, if not universal coverage has been accepted by just about everybody and is no longer even a matter for debate.  The goal of "bending the cost curve," however, remains elusive.  The WSJ looks at a few different mechanisms for funding this expansion of coverage:

Check, Please: Four Ways to Pay the Health-Reform Bill - Health Blog - WSJ
Higher taxes on alcohol and tobacco
Pros: These taxes, a popular way to pay for insurance expansion (see: Schip), also do “double duty” by reducing use of products that harm health.
Cons: They raise only “modest” amounts of funds unless the taxes are hiked so much as to be politically unpalatable.

Taxes on employer-sponsored health insurance
Pros: The government gives up some $246 billion a year in income and payroll taxes that could come from taxing health benefits, Oberlander says. Capping this tax exclusion could bring in substantial amounts of money. The idea is getting some real consideration in Congress, WSJ reports.
Cons: The idea is very controversial, and would be difficult for Obama politically, since he would be reversing course after opposing such a proposal from John McCain during the campaign. Employees in expensive insurance pools (such as companies with older workers) might also be unfairly penalized.

Employer mandates
Pros: Requiring employers to either provide coverage to their workers or pay a tax would build on the current employer-based system. This would be a political advantage, Oberlander notes.
Cons: If small businesses are exempted, as has been suggested, this won’t bring in as much money as it otherwise would.

Individual mandates

Pros: It’s possible to get bipartisan agreement on these, especially since the insurance industry believes requiring people to get coverage is a key step toward avoiding coverage rules that limit benefits for sicker patients.
Cons: Taxing people who don’t obtain coverage would be controversial. And many of the uninsured have low incomes and would require government subsidies.
It's worth noting that these are not the only options on the table, and it's a given that some sort of individual mandate will be included, as will some sort of pay-or-play for employers.  I've heard some rumblings that Obama's proposal to limit certain itemized deductions for higher-income taxpayers may not be entirely dead.   This may be the most challenging part of reform; while we all obsess over the Public Plan option, the financing will make or break the ability of any final package to receive Congressional approval.

Obsidian Wings: Comparative Effectiveness Research
You'd think that doing research to figure out which treatments are most effective would be an obviously good thing. But no: it is, apparently, the first step on the road to socialized medicine. A lot of the attacks rely on this "first step" argument. For instance, the Heritage Foundation wrote that "The type of information collected by CER could eventually be used inappropriately if a "Federal Health Board" was created to decide which types of treatment would be available to whom and when."

It could be used to do bad things! At least, if a board that doesn't exist were created and told to use this information! Pass me my smelling salts.
It's worth pointing out that the Swiftboaters over at Conservatives for Patients' Rights are already seizing on this in their ads.  It's not as catchy as the Harry and Louise ads, nor as scary, because it's kind of complicated.  But it's no less shameless in its dishonesty and scaremongering.  But when FUD is all you have, you gotta ride that horse...

One interesting thing worth noting is although conservatives insist as an article of faith that Obama secretly intends to impose a single-payer plan on the nation, the single-payer advocates have been completely shut out of negotiations at all levels, and they're hopping mad about it:

Daily Kos: Can No One Rid Us of These Single-Payer Advocates?
The powers-that-be are not even going to publicly discuss single-payer. Despite the immensity of the issue, there will be no three-day, televised hearing devoted to witnesses discussing single-payer's pros and cons in full public view. Instead, the whole single-payer idea is being treated as if it were a terrorist. They've shackled it, put a hood on it, renditioned it and disappeared it.
Open Left:: A Note to Single-Payer Advocates

- Most progressives, and many millions of Americans, support the concept of a single-payer health care system.

- Those in Congress, like Sen. Max Baucus (D-MT), who refuse to consider single payer in the debate over health care are the enemies of single payer.

[P]rofessional advocates of single payer seem to believe their biggest
enemies are those who support single payer, but short of that, would
also support a robust public option in a non-single payer universal
Sirota's point is that if single-payer advocates who are reasonable and open to compromise were included in the debate, they could be positive advocates for reform, but reasonable single-payer advocates tend to be in short supply.  The fervor, dogmatism and tactics of the single payer zealots serves only to ensure that they are not taken seriously and that their enthusiasm will go to waste.  Pity.

This is not good

I go to the cafeteria to get some breakfast. I come back, and there is a new patient in room three.  There are four police officers in the hall, laughing and having a great time.  "You're gonna love this one, doc!"

Uh Oh.


Updated by popular demand:

Turns out it was a drunken psychotic patient, covered with his own various bodily fluids.  He had been living under a bridge and his hygiene was as poor as you might expect.  He had been picked up for disorderly conduct, and was brought to us for a psych eval.

BUT - and this is key - he had an outstanding FELONY warrant!  So the cops had to take him to jail.  One quick medical screening exam later, the guy is back in the squad car and off to jail.

I made a lot of friends today.  The nurses were delighted that I didn't insist on blood tests, a banana bag and a psych eval in the ED.  The cops were delighted that they didn't have to hang out and guard him for several hours.  He was eminently medically stable for jail (where psych and detox evals are also available).   The nurses were so happy that I didn't do the million-dollar CYA work-up that they went out and bought me Starbucks!

12 May 2009

The Proceduralists' Lobby Strikes back

I must have missed this: Last week, 90 bipartisan members of the House of Representatives sent a letter to House leaders expressing their opposition to one proposed option to increase funding for primary care services as part of health care reform.  The letter, written by Reps. Shelley Berkley (D-NV) and Mark Kirk (R-IL), stated the undersigned Members would not support increasing payments to primary care by reducing payments to specialists and other health care providers.

This is in response to the floated policy which would reduce payment to proceduralists to fund a 5% increase in primary care.  I knew the specialties would fight it, but I didn't expect that they had this much clout, especially being such a fragmented group of interests.

It will be interesting to see whether this is just posturing or whether this bipartisan group has enough clout to block the Senate's proposal.

11 May 2009


Mythbusters... do I really need to say more?  They have gotten tired of simply blowing things up (which is itself hard to believe, but apparently it can happen) and they are now moving into the field of rocketry.

They recently tested a myth regarding whether two trucks colliding head-on could fuse the metal together.  But trucks are so mundane, and only travel 60, 70 miles an hour.  Bah.  How about if we took a subcompact car and slammed a rocket-propelled sled into it at SIX HUNDRED miles an hour?  Now you're talking!  Does this satisfy any scientific inquiry?  Of course not.  But oh damn oh damn oh damn is this cool:

and in super-slo-mo:

The moment of truth:
MythBusters : Interactive Video : Discovery Channel

Holy fargleschnidt!  The car is literally vaporized!  Don't miss the frame-by-frame on the Discovery Web Site, too.

Good lord, please don't ever let these guys get their hands on any fissile materials. 

10 May 2009

Happy Mother's Day

Mother's Day Haiku!
teeth marks on shoulder
"I bite you instead of kiss!"
painful toddler love

don't pull out your hair
no matter what the kids do
will just grow back gray

sleep in the bath tub
copy of Dwell is destroyed
me time so worth it

the penis custom
off limits in shopping cart
important lesson

tiny baby socks
become bigger stinky ones
still love the feet, though

"I love you, Mommy."
melts my heart every time
even cleaning poop

More through the link.

09 May 2009

Barack's Funny

He has good writers...

#nerdprom is always good for a laugh ot two.

(hashtags work in blogger, right?)

My first patient today


A nice guy who fell early this morning playing racquetball at the YMCA.  He dislocated his left thumb and had a pretty impressive palmar laceration at the joint.

I spent quite a while chatting with him while I sewed up the laceration -- one of the true pleasures of my job.  He was a very athletic guy, we both belong to the same Y, and we even knew a few people in common socially.  In fact, his wife, also at the bedside, was vaguely related to one of my partners.  We talked about the different sports we enjoy, and how the skiing and snow had been this year up at the pass.  We talked about my work, and his work, and his experiences in the military and in the war.

Not in Iraq, but in the Philippines, in 1944.   He was 85 years old.

Damn.  Still skiing and playing racquetball at 85.  I marveled at that fact, and he shrugged it off, "What do you expect from an old Marine?"

Talk about winning the lottery, or, as Matt once put it, "Doing the long slow victory dance in the end zone of life."

08 May 2009

The future of primary care

Nurses: A Key to Health Care Reform - Swampland – TIME.com
One of the few things that just about all sides agree upon in this health care debate is that we need more primary care providers -- lots more. And an already serious shortage will only get worse if we succeed in expanding coverage to some or all of the 47 million Americans who now lack it.  [...]  The good news, however, is that there is a large army of reinforcements out there--primary care providers who are proving their worth every day, particularly in underserved areas like rural America. They're called ... nurses. More specifically, nurse practitioners. In 2006, there were nearly 145,000 nurse practitioners--registered nurses with advanced training--practicing in America. In 2007, another 3,700 graduated from masters degree and postmasters programs.
Karen Tumulty has been exceptional in her health care writing lately.  This piece, while entirely accurate, has a disquieting element to it.  Physician-provided primary care is dying, and in the future will be provided by Mid-Level Providers (including NP's and PA's).

This is not altogether a terrible thing.  There's an efficiency argument for MLP's in primary care: they are more affordable in large numbers.   And there are not enough physicians to provide the needed service.  Quality is more concerning.  Within a limited scope of practice and with reasonable supervision, MLPs can provide great quality primary and acute care.  But MLPs are not physicians.  I've worked with a lot of MLPs over the years, and many of them were very good at what they did.  My experience, however, is that even the less-exceptional physicians I have worked with had a deeper breadth of knowledge and skills than the best MLPs.   So while I see a role for MLPs and I respect them for the abilities they have, supervision is essential.  But, as referenced in the article, many states allow near-independent practice by NPs in particular, and then greatest need for MLPs is in sites where physicians are not available.  When a provider gets in over their head, it can be very dangerous, especially when they do not realize that they are out of their depth.

This situation is suboptimal.  The ideal would be to have enough physicians to provide these services without compromising quality.  But the deathgrip that proceduralists have had on the compensation system (the RUC) has bled primary care dry financially and in personnel.  Even if the health market reform rejuvenates primary care training, it will be five to ten years before the new PCPs hit the market in meaningful numbers.  If Obama is successful in accomplishing universal coverage, this lag time will be too long, and MLPs may fill the market niche in the interim.

06 May 2009

Flight Patterns over New York

Cool article from Wired. It's about a mathematical model of the redesign of the departure paths, hopefully reducing delays and congestion.

Being a fan of the iPhone game Flight Control, I can appreciate the complexity of the system.  Um, not that it makes me an air traffic controller or anything.

Some interesting tidbits about the Public Option

Democratic Senator Chuck Schumer teased us on Monday with possible details of a public plan element of the impending health market reform proposal.  Specifically, he laid out some principles for how the plan should operate, and it's encouraging both from policy and political perspectives.

Ezra Klein writes:
Chuck Schumer just forced the Senate Finance Committee's Health Care Coverage Roundtable to address the public plan. And give Schumer some credit. He didn't hedge. "Just as bad as a public plan with an unfair advantage," he said, "is no public plan at all. My colleague from Kansas said the American people don't want the government involved. Well, let me tell you, the American people have some problems with the government. But they have a lot more problems with private insurers."
The general principles for the operation of the public plan were summarized in this NY Times article from yesterday and they directly address the concerns voiced by Senate republicans and the insurance industry:
¶ The public plan must be self-sustaining. It should pay claims with money raised from premiums and co-payments. It should not receive tax revenue or appropriations from the government.

¶ The public plan should pay doctors and hospitals more than what Medicare pays. Medicare rates, set by law and regulation, are often lower than what private insurers pay.

¶ The government should not compel doctors and hospitals to participate in a public plan just because they participate in Medicare.

¶ To prevent the government from serving as both “player and umpire,” the officials who manage a public plan should be different from those who regulate the insurance market.
Also, Schumer said that the public plan "must be subject to the same regulations and requirements as all other plans" in the insurance market, including minimum benefit levels and the maintenance of adequate reserve funds.  As Ezra notes:
The private insurance industry [is] in a tricky space. They had based the whole of their argument against the public plan on the idea that it would not compete on a "level playing field."
And this proposal neatly eviscerates that line of attack (assuming that the attacks will be honest, a ridiculous and naive assumption).   The only "unfair" advantages left are those which might be in other terms be described as efficiencies -- scale, no profit motive, lower administrative expenses, inexpensive executive compensation, no need for advertising, etc.  You can assume the "unfair competition" meme will persist, but prior to this proposal it was based on faulty assumptions of a worst-case liberal-dream-plan that did not materialize.  This more limited public plan is exactly the sort of offering that key republican Chuck Grassley hinted he might support.  What's the critical difference that makes this palatable to conservatives?  Physician and hospital reimbursement:
The public plan should pay doctors and hospitals more than what Medicare pays.
What this means is that the public plan's reimbursement rates must either be set competitively by going out and negotiating for provider networks like the private insurers do, or (more likely in my opinion) that rates would be set by an autonomous board, leaving providers free to choose whether or not to participate in the public plan.  The great fear, and a legitimate one, was that the public plan's rates would default to the Medicare rates which are already unsustainably low.  This would allow the public plan to underprice care and have an insurmountable price advantage over the private insurers.   However, competitive pricing negates that possiblity.

This levels the playing field.

Predictably, the insurance lobby continues to oppose the public plan, but their arguments are becoming steadily weaker:
Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group, said, “We are very, very grateful that members of Congress have been thoughtfully looking at our concerns.” But she said she still saw no need for a public plan “if you have much more aggressive regulation of insurance.”
Funny to see the industry arguing in favor of increased regulation.  But the road to the public plan is by no means clear: Sens Snowe (R-ME) and Specter (R D-PA) are skeptical, and Sen Nelson (D-BC/BS) is outright opposed:
Nelson’s problem, he told CQ, is that the public plan would be too attractive and would hurt the private insurance plans. “At the end of the day, the public plan wins the game,” Nelson said. Including a public option in a health plan, he said, was a “deal breaker.”
This, opposition, I am sure, has nothing to do with the fact that the insurance industry is Nelson's single biggest campaign donor. I also still find it bizarre and amusing that the same folks who claim that government-funded health insurance would be a bureaucratic nightmare also argue that it would be "too attractive" for private industry to compete with it. 

That might have been the case if the public plan had retained huge systematic advantages or had been funded through general reveues.   Schumer and the Finance Committee seem to be bending over backwards to eliminate all possible "unfair" advantages of the public plan.  I think this is a good thing -- bring on fair competition, and let's see who wins.  I suspect that nobody will "win," but that the government-run and private insurance plans will co-exist with their differing strengths and weaknesses complementing one another.  

One thing that I can predict is that the opponents of reform will now be reduced to deliberate inaccuracies (what used to be called "lies") in arguing against reform.  They will not be able to oppose the proposal with the same talking points they have used to date, and will revert to arguing against the imaginary socialized medicine plan that they wish Obama and the Democrats were putting forward.

05 May 2009

Working Americans Losing Insurance


From the Center for American Progress:
Employers have shed 5.1 million jobs in the last 15 months. Three industries alone—manufacturing, construction, and professional and business services—account for nearly three-quarters of total jobs lost. Manufacturing has shed 1.5 million jobs—1.1 million in durable goods, 367,000 in nondurable goods manufacturing—construction has eliminated 1.1 million jobs; and professional and business services have cut 1.2 million positions.

We estimate that 2.4 million workers have lost the health coverage their jobs provided since the start of the recession, based on data from the U.S. Census Bureau and the Bureau of Labor Statistics. Approximately, 1.3 million of these losses have occurred in the last four months. More than 320,000 Americans lost their employer-provided health insurance in March alone, which amounts to approximately 10,680 workers a day.
Just to be clear -- these numbers do not include the displaced workers who went on to find new jobs or new coverage; these are the people newly and currently uninsured.


Never waste a good crisis, they say.  Universal health insurance was a good idea two years ago.  It's becoming a better idea every single day.

They're like the Code Pink of Health Care

Or the Ron Paulites of Insurance, if you will.

Order in the Senate! Single-Payer Advocates Disrupt Hearing - Health Blog - WSJ
Advocates of single-payer health care are getting feisty!

Eight of them caused a scene at the start of a health-care hearing of the Senate Finance Committee today, getting up one by one and complaining that nobody who shared their view was getting a voice, as Dow Jones Newswires describes it. They were able to continue their interruptions because they were staggered throughout the room. Just as one was escorted out by the police, another would chime in.
You know, I'm sympathetic to these guys, I really am. And I think they represent a useful voice on the left to keep the politicians from hewing completely to the center-right.   But this is just dumb, and not helpful.

This goes back to my earlier post today about irrelevance, and being able and willing to make compromises.  Inflexible zealotry and dogmatism don't get much accomplished.  A superficial surveillance of the political landscape today shows that if Single Payer is your thing, then you've already lost.  There's no support for it, and even active antipathy towards it from your ideological allies, never mind your enemies.  Being louder and more obnoxious does not advance your cause, and if anything, it further marginalizes you as an unserious participant in the negotiations.

A better strategy would be for PNHP to pivot to full-throated advocacy for a robust public option plan with built-in advantages over private insurance.  Not my preference, BTW, but an achievable political goal in line with their ideological principles.  But these idiots squander their standing and their political muscle, such as it is, by insisting on the impossible.

Negotiating your way into irrelevance

Time's Karen Tumulty writes in her latest article:
When Barack Obama informed congressional Republicans last month that he would support a controversial parliamentary move to protect health-care reform from a filibuster in the Senate, they were furious. That meant the bill could pass with a simple majority of 51 votes, eliminating the need for any GOP support. Where, they demanded, was the bipartisanship the President had promised? So, right there in the Cabinet Room, the President put a proposal on the table, according to two people who were present. Obama said he was willing to curb malpractice awards, a move long sought by Republicans that is certain to bring strong opposition from the trial lawyers who fund the Democratic Party.

What, he wanted to know, did the Republicans have to offer in return?

Nothing, it turned out. Republicans were unprepared to make any concessions
(Emphasis added)

What an interesting anecdote. First, again, there is the promising tease that Obama is using liability reform, long-needed but consistently blocked by Dems, as a sweetener to try to win some GOP support for reform.

Second, how remarkable is it that the Republican caucus seems to have nothing whatsoever to bring to the table here? In 1993, Bob Dole made the decision to block health care reform at all costs, and he had the power to do so, with 43 votes (abetted by many recalcitrant Dems). But this year, gambling on obstruction looks like much less of a sure bet, given both the electoral reality and the greatly heightened consensus that real reform is needed.

So what's their game? I really don't get it. If they don't sit down with a real interest in compromise, then the Dems will steamroll them with somewhere between 51 and 63 votes, depending on a lot of things, and the GOP will wind up actually voiceless in the whole process. You can make an argument that they are effectively voiceless as it is, and there's an element of truth to that, but that's what happens when you are in a greatly diminished minority. The difference between having a small input into the final product and having no input seems to have enough value that you would expect them to swallow their pride and get to work salvaging as much as they can out of a bad position.

I dunno. Maybe they are just holding the line, reprising Dole's role as "Senator Gridlock" and hoping against hope that they can regain some relevance through obstruction. Maybe their diminished caucus is so amazingly ideological now that all the moderates have been purged that there is no capability for compromise any more. Maybe McConnell really is just not up to the task of leadership. From a purely partisan view, this is not altogether bad, since it means that there is less incentive for the progressives in our party to collaborate with conservatives and weaken the final product.

It would be nice, though, if the GOP could at least hold out for that malpractice reform clause...

[Addendum: though the Senate GOP Leadership is not participating, it should be noted that per report, Chuck Grassley, the Senate Finance Ranking Member, is doing good work at the committee level. Whether he signs on to the final product is an open question, and he probably will not. But there is (at least) one Republican interested in the grown-up mechanics of governing.]

Point of Order

Matthew Yglesias » Killing Health Reform With Kindness
Ezra Klein observes that Arlen Specter says he’s for the Wyden-Bennett approach to health care reform but also says he’s against eliminating the tax exemption for employer provided health care. Inconveniently, eliminating said deduction is part of the Wyden-Bennett plan. That’s how you pay for it.
This came up in the comments the other day, also.  Bastiat's Ghost (great handle) wrote:
We could also remove the link between health coverage and employment. The problem is Shadowfax is against it in spite of the fact that the McCain health reform plan was originally proposed by Jason Furman a current adviser to the President.
It would be inaccurate to say that I don't support this de-linkage.  In fact, I'm a long-time enthusiast for the Wyden-Bennet Healthy Americans Act, which does exactly that.  I don't think the HAA has much of a chance of being the legislative vehicle through which reform is enacted, which is a pity.  One problem is that people who tend to agree that major reform is needed also tend to be reasonably content with the coverage they currently have -- or conversely, they are easily frightened by the unknown changes they might be required to change to under a reform plan.  The beauty of the Baucus plans that are under discussion is that they generally allow the employed the option of retaining their current coverage, assuming their employer continues to provide it.  But the HAA would create a radical restructuring of the market and people might have to change plans, and it's just too much to swallow, politically.  (Prove me wrong, Congress!)

It is true that I opposed the McCain plans which also de-linked employment and insurance and taxed the employer-sponsored plans as income.  The primary reason that I opposed these steps is not because they are destructive in and of themselves, but because the plan did not replace the current insurance options with anything better.  

Now if universal coverage is going to pass, it will need to be funded somehow.  The Congress didn't like Obama's "down payment," I gather, so it's off the table.  Pity -- it was a reasonably progressive mode of funding it.  If the next best way of funding it is through taxing health benefits, I am OK with that, though it seems regressive and suboptimal to me.  The funding issue, to me, is a case of not letting the perfect being the enemy of the good.  If there really are benefits of pushing people into the individual insurance markets (or if there is eventually a viable public option) then it might even wind up a feature, not a bug.

From the Imperial Veterinary Clinic

 Anatomy of an AT-AT

Seriously, is this not the greatest thing ever?

Via (where else?) Street Anatomy.

Is this for real?

Andrew Sullivan linked to a disturbing report of anti-gay violence in Iraq.  There's a lot of real, confirmed repression, abuse and murder of homosexuals in the Middle East, so I don't want to come across as denying or minimizing that fact.  It's a bad, dangerous place to be gay.  But this sounds more like something out of an urban legend:

Iraqi Gays Face Gruesome Torture/ Murder Technique
As the murder campaign targeting Iraqi gays intensifies, a leading Arabic television network last week revealed the use of a horrifying new form of lethal torture against Iraqi gay men - anti-gay Shiite death squads are sealing their anuses with a powerful glue, then inducing diarrhea, which leads to a painful and agonizing death. The use of this stomach-turning new torture was first reported by the Al Arabiya network, which is headquartered in the United Arab Emirates and was alerted to the story by a leading Iraqi feminist and human rights activist.
Does this sound plausible to you? I'm skeptical.

So what might this mean?  How exactly does one seal an anus?   Let's say they have some version of dermabond, maybe something a bit stronger for the sake of argument.  Then they force the victim to drink GoLytely (an electrolyte solution which is used to "wash out" the bowels prior to surgery or endoscopy).  Would this kill?  Reliably?  I dunno.   Colonic obstructions are serious -- they cause severe retrograde vomiting, but that would not be fatal in itself.  If the obstruction persisted a while, exacerbated by GoLytely, I can see it causing perforation, leading ultimately to sepsis, and death.   But that would really take some time, time in which the anal seal would need to remain intact, which seems to me to the the weak point in this supposed technique (no pun intended).

Bear in mind that the anus is not like a piece of household copper plumbing -- you can't just "cap it off" and assume that it'll hold its seal against whatever internal pressures are generated.  It's a soft, mobile and malleable orifice ending in skin and mucosa.  The pressure generated by a full rectum, cramping and straining and trying to have a bowel movement, would be quite high, so a very robust seal would be required to completely obstruct this.

First, I don't know how well Dermabond or other glues would hold to the moist, oily skin down there.   Second, the tensile strength and flexibility of these glues tends to be not so great, which is why you don't use it over elbows and other places where there's a lot of skin tension and flexion going on.  Finally, even if the tensile strength of the glue and its adhesive properties were strong enough for the application, the mechanical properties of the skin and mucosa of the anus are not that strong.

To put it bluntly, even if the glue adhered, and even if the glue were flexible and strong enough to withstand the pressure, the skin itself would probably tear as the victims involuntarily strained and the stool would blast right through the "seal."

Would that hurt?  Yeah, like crazy.  Would it cause bleeding and injury?  For sure.  Would it kill?  No way.

The other element of this story which sounds like an urban legend is they way it takes what heterosexuals would (wrongly) assume to be the central element of homosexuality, the anus, and does violence to it in a way that's intended to be ironic or perversely fitting.  The gays like to put things up their butts -- but what if their butts were sealed off?    The anus has long been used in a manner to torture or kill in the past -- forced sodomy and impaling being the common mechanisms.  So if you want to murder yourself some gays, what's wrong with the ol' broomstick technique?  It's a lot simpler and more efficacious than this convoluted and rather implausible mode.

Allegations like this are all-but-impossible to disprove, and the limits of cruelty displayed in Iraq in recent years are themselves beyond belief.   So it would be presumptuous in the extreme to say it's impossible.  But I call Bullshit on this one until more substantiated facts come to light.

04 May 2009

Kent Brockman Moment

Good Lord, it's almost as if they were trying to recreate the Simpsons here:

The Homage:

The Original:

"Earlier in this broadcast, I said a word so vile that it should only be uttered by Satan himself while sitting on the toilet. I apologize, and will make a large donation to charities that fight teen cursing."

The Simpsons 1822 You Kent Always Say What You Want

(apologies -- couldn't embed; scroll to 10:05)

No story, just a picture

Bacterial meningitis with cerebral abscesses.  Immunocompetent patient.  You just don't see this stuff any more.

File under "better thee than me."

03 May 2009

Mapping the Uninsured

This is a cool map generated by Jim Gimpel, showing the distribution of the uninsured nationally.

He makes the point that:

The geographic concentration of the uninsured seems a bit ironic, given that the South and Southwest are not known for being Democratic strongholds agitating for a universal-coverage-single-payer system. But most of the uninsured fall heavily among the ranks of non-voters. The Republican congressional delegations from these states have little political incentive to work on this issue with President Obama. But the President doesn’t look like he needs them, either.
Good point.

The thing that I find striking is how otherwise demographically different states can dramatically differ in their uninsured rates. Look at Iowa and Nebraska, or Minnesota and the Dakotas. Clearly there's some key difference in the laws and regulations of those states which makes it easier to be uninsured there. For that matter, Alabama and Mississippi are quite different as well, despite being comparable in other ways.

And what's up with Florida? For a relatively affluent state, it's almost as bad as Texas, despite having a far smaller illegal immigrant population.

I love maps.

02 May 2009

Her Morning Elegance



An unforgettable business card:

We start with 100% beef jerky, and SEAR your contact information into it with a 150 WATT CO2 LASER.

Screw die-cutting. Forget about foil, popups, or UV spot lamination. THESE business cards have two ingredients: MEAT AND LASERS.

Can this be for real? Oh, please, please, great FSM, let it be real.

01 May 2009

Not my specialty

The medical office building at our facility is located right next to the ER.  The entrance to their clinic is maybe thirty yards from the ER's main entrance.   A lot of the docs use the ER waiting room as the route into the hospital proper; it's shorter and drier and the state of the waiting room gives them a sense of how many calls they are likely to get on any given day.  So it was with no surprise that I saw one of our general surgeons standing in the waiting room as I slipped out to run to the cafeteria for lunch.

She quickly buttonholed me, "Shadow, I need your help with something."

This surgeon is one of our best -- smart, witty, always willing to come in and do the right thing.  But she takes no bullshit either.  We have a very good relationship, and so I stopped to see what it was she needed.

"I was in clinic this afternoon," she explained, "and I started feeling a little off.  Sweaty and tired.  I mostly ignored it, because I've got some cases this afternoon and I wanted to get through clinic on time, but then I started to feel worse.  I threw up once, and was feeling a lot of indigestion.  So I went into the back room and did this ECG on myself."

She handed me a piece of paper, and I glanced at it.

"What do you think?  Is this real?"

Inferior MI
(Click to embiggen)

"Yeah," I said, scanning the cardiogram.  "This is real.  Are you still having pain?"

"Well, I don't feel good, but I don't have any pain.  I took an aspirin and found some nitro, which really helped with the indigestion.  But now that you mention it, I'm feeling a little lightheaded."

"That's probably the nitro talking," I said, taking in her rather pale complexion.  "Let's get you in back."

"But my cases..." she trailed off.

"Will have to be canceled." I said firmly, as I grabbed a wheelchair and flagged down the triage nurse.

"Whatever you say.  I'm out of my depth here.  You know, this really isn't my specialty." And with that resigned grumble, she slumped down in the wheelchair and gave herself over to our tender mercies.

She was actually profoundly hypotensive (nitro and inferior MI's are often an unhappy combination).  But that perked up with a bit of fluids.  Although she was young, early fifties, she had some bad genetics working against her, with a strong family history and wicked high triglycerides.  She didn't like the cardiologist on call (with reason, I must admit) and so we called one of her partners in her multispecialty group who came right down.  She was whisked off to the cath lab where her RCA was stented (door to balloon 45 minutes, thankyouverymuch) and as far as I know has made an uneventful recovery.

No great teaching point here, other than perhaps that women have different symptoms of heart disease than the classic ones.  I just thought it was striking that this was the first and probably only time in my career I have seen someone self-diagnose their MI with an ECG prior to coming in!

Swine Flu in the Hundred-Acre Woods

I wish I knew who created this so I could thank them...