30 November 2010


xkcd: Positive Attitude

This made me sad, but also kinda cheerful. Click through for the rest of the comic. Apparently, Randall Munroe, the author of the brilliant nerd comic xkcd is dealing with a serious family illness. I've been reading his stuff for years. Weird that you can worry about someone you don't know and will never meet. Hoping that things work out OK for them, whatever it is that is going on.

This is my favorite xkcd strip ever: it involves velociraptors!

SGR Fixed! Now we never have to worry about that again, right?

Maybe not:

The House passed a one-month, $1 billion “fix” to the Medicare physician payment formula Monday afternoon, two days before doctors were scheduled to take a 23 percent hit in Medicare payments. 

The House approved by voice vote the Senate’s plan to fund the fix through cuts to payments for certain therapy services. The bill, which had passed the Senate on Nov. 18, now awaits the president’s signature.

If signed into law, a 2.2 percent update in physician payments will be put in place through the end of the year. This will be funded by expected savings from a 20 percent reduction in payments for therapy services. 

I admit to being a little baffled as to why they enacted a ONE month fix -- this just kicks the ball further down within the lame duck session, as the new Congress does not take office until, what, Jan 5? So something further will be needed this session to prevent the 25% cuts from taking effect.

Background (for those new to the game): The SGR was a formula inserted by Republicans into the 1997 Medicare Modernization Act which was intended to provide a modest restraint on the growth in Medicare Part B payment to physicians: the original estimate was that it would save $12 billion over ten years. But they got the formula wrong -- badly wrong, and it soon began requiring deeper and deeper cuts in physician reimbursement, far beyond those intended by those who wrote the law. Congress never acted to fix the formula, only applying one- and two-year patches which allowed the mandated cuts to compound without ever letting them go into effect. But the cost of not fixing the SGR goes up with every time Congress punts, making it harder and harder to find new dollars to offset the ever-more-expensive "Doc fix." Apparently we are up to $1 Billion per month, now, which is more than I last heard. During the health care reform debate, when Congress again punted on this issue, the ten-year costs were estimated at something like $300 Billion. 

It's taken a political given that these cuts cannot ever be allowed to go into effect, as the result on the program would be catastrophic: Since Medicare is in most localities already a low-payment insurer, a 25% cut in reimbursement would cause a lot of docs to simply drop out of the program, or more likely to severely curtail the number of slots in their practice available for medicare patients. In our community, I know that it is extremely difficult for a new medicare patient to find a physician that will accept him or her as a patient. That will only get worse. This problem wasn't created by the SGR, but it has certainly be exacerbated by it: as Aaron Carroll at The Incidental Economist wroteThere’s nothing like the threat of a double-digit percentage payment cut to make a one or two percent increase look large. The SGR has in fact enabled Congress to slowly defund Medicare payments to physicians in this manner, with the effect that, according to the Center for Budget and Policy Priorities

The reimbursement rate for physicians next year will still be 17 percent below the rate paid in 2001, adjusted for subsequent increases in the costs that physicians incur in providing services as measured by the [Medicare Economic Index].

If Congress were to allow the cut to take effect in January, which it clearly will not do, the reimbursement rate would be 35 percent below its real 2001 level, an outcome that cannot be justified on policy grounds and one that would risk inducing large numbers of doctors to stop accepting Medicare patients.

While there is a sort of "cost containment" good news element to this -- some parts of Medicare expense can in fact be regulated -- it's been done in an accidental, jury-rigged fashion, under constant threat of catastrophe, and without a lot of benefit for patients for the amount of pain exacted from both patients and physicians. 

Put it another way: if physicians were forced to give up 17% of their inflation-adjusted revenue in a reform, I would expect this to come with some sort of sweetener, something which would improve the quality or efficiency or convenience of care. Because it will have consequences: currently, docs simply limit access and increase volume to make up the loss. What could policymakers have gotten in exchange for that 17% if it had been part of a carefully designed plan? But we (as patients and as physicians) got nothing of value for that concession.

Now, physicians will probably be asked to give up more, whether as part of bundling, P4P, or by being forced into vertically integrated ACOs. You can see from surfing around on the medical blogs how well that is going to be accepted on top of the previous decade's worth of cuts. It may be that the bunker mentality created among physicians by the SGR will play a significant role in inducing docs to reject further participation in payment reform.

Aaron Carroll summed it up well:

The part that makes me despair is the complete disconnect between what groups say they want, and their displeasure when they get it.  People seem to be upset that Medicare costs so much; but any attempt – even successful ones – to slow those cost increases is met with howls of rage and screams of rationing.  People don’t seem to realize that the money we spend in Medicare isn’t going into a pile somewhere.  It goes to doctors and nurses and hospitals and companies.  When you spend less, those people make less.  All of them.

You simply can’t have it both ways.  You either choose to spend less and piss people off or spend more and piss different people off.  Either way, you’re going to piss someone off.  A good system would try to make that decision rationally.  But at least it would make a decision.

Congress, as a body, doesn't seem very effective at making decisions these days.

29 November 2010

Fearful Symmetry



TIGER, tiger, burning bright

In the forests of the night, 
What immortal hand or eye 
Could frame thy fearful symmetry?

She was a strange lady: the triage nurse visibly rolled her eyes as she gave me report. "Seizures" 20 times a day for weeks. Strange auras. A poor and unreliable historian. She was a a heavy drinker with unspecified mental health problems. She'd had one of her "episodes" at triage and it had looked pretty fake -- certainly not an epileptic-type seizure.  It did not sound like a promising case, at least not in the sense of finding a "real" diagnosis or a productive treatment plan. 

Until the patient arrested, of course. That got our attention pretty quick!  She had just been put on the monitor, and the nurse happened to be in the room and saw her go out. We called the code, and hooked up the machines and gave her the good juice, which fixed her.  For the moment.

This is what the monitor showed:

Uploaded with Skitch!

Is that not beautiful? This is Torsades de Pointes, an arrhythmia which is a sub-type of ventricular tachycardia in which the QRS axis twists around the myocardium. It's linked to long QT syndrome and low magnesium.  You can see in the above image how symmetric and regular the pattern is as the electrical focus moves around the heart.

There's not much more to the story: This lady, once we converted her back into sinus, has a corrected QT interval somewhere around 600ms! It was likely related to a medication she was taking. She wound up going back into torsades about three times, requiring recurrent cardioversion, before the Mag and lido kicked in and stabilized her rhythm.

If there's a point to the story, I suppose it's that even weird/crazy patients have bad things happen to them and you can never assume someone is just nuts. But mostly I wanted to share a lovely picture.


25 November 2010

Hazy Shade of Winter

I'm off to the beach for a few days. Enjoy yourselves and have a great holiday!

24 November 2010

Fricking Amazing

This blows me away:

Is this for real? It seems actually not possible, but then I don't know much about rugby. I do know the All-Blacks are supposed to be pretty good, though.


On nonpartisan politics:

I've always been kind of bummed at the general low rate of participation in American democracy. During my lifetime, the voter turnout rate has been something along the lines of 50%-ish in presidential years and 35% in midterm years.  What does that say about the American electorate? That they are to passive/uninformed/disinterested to bother exercising a fundamental right that people in other places and times have fought and died for? Or is an indictment of our system -- that the government is so dysfunctional that people have written it off and given up?

However, here in my home state in the upper-left corner of the US, we have recently gone to an all-mail-in vote. (I think there's one county that still has traditional voting.) I was listening to the news yesterday and heard that the Secretary of State announced that, this year, 71% of all voters cast their ballots!  71%! That's just stunning.  Oregon, also vote by mail, is about the same, and pushes the 90% threshold in Presidential years.

Why doesn't every state do this?

It's so convenient: you fill out the ballot and send it in whenever you like. You can take the time to research the gajillion voter initiatives (when in doubt, vote no), carefully consider the down-ballot and judicial races, and talk it over with your family as you fill out your ballot. You don't need to stand in line, it doesn't matter if the weather sucks. There are no worries about voter intimidation or minority neighborhoods with inadequate numbers of voting machines/ballots. You don't need to worry about electronic voting machines miscounting your vote. You don't need to juggle work and/or childcare to make it to the polls during the specified hours.  

I admit that I kind of miss the civic ritual of going to the poll, but we've invented a new ritual in our family: I involve my kids and have them help me fill out my ballot, and talk about what we are voting for and why. I'm not sure they really understand it yet, but they will in time.

I suppose there are hypothetical concerns about fraud with mail-in ballots, but those have never really been substantiated as actually happening, and quite honestly even if they did occur, would be marginal in their effects compared to the fact that DOUBLE the number of voters actually cast their ballots in such systems.  How can such increased participation NOT strengthen our democracy?

I've noticed that republicans generally oppose measures that would tend to increase access to the ballot and favor those that would restrict it (voter ID laws, motor voter, etc). The thinking is that making it easier for poor/elderly/minority voters to vote will disproportionately help democrats. But that doesn't seem to be the case here. Despite being a "deep blue" state, we have had the last three major statewide elections (Gov x2, senate) be decided by a few thousand votes. There's real parity here, and while it's impossible to know what the state would look like under traditional voting, it certainly doesn't seem to have disadvantaged republicans too much.

Things change slowly, but more and more states are adding "early voting" and I wonder if ultimately most states will go towards voting by mail.  I really hope they do.

23 November 2010

Health Care reform law gaining public support

GOP hardliners soon to be in control of the House have made repeal of the detested healthcare reform law a cornerstone of their agenda, despite the impossibility of actually being able to repeal it, politically, at least until an election or two has passed, and despite the fact that their ascent to power had more to do with the terrible economy and high unemployment than any mandate to repeal the law. It seems that, finally, there may be movement towards increased public support for the law.  A new McClatchy poll shows a majority of Americans now in favor of the law:

A majority of Americans want the Congress to keep the new health care law or actually expand it, despite Republican claims that they have a mandate from the people to kill it, according to a new McClatchy-Marist poll.
The post-election survey showed that 51 percent of registered voters want to keep the law or change it to do more, while 44 percent want to change it to do less or repeal it altogether.
Driving support for the law: Voters by margins of 2-1 or greater want to keep some of its best-known benefits, such as barring insurers from denying coverage for pre-existing conditions. One thing they don't like: the mandate that everyone must buy insurance.

Of course it is the mandate that makes the whole thing hang together. And it's hardly news that people like the individual provisions and protections found within the law. From a recent Kaiser Family Foundation poll:

I suspect, depressingly, that the GOP will continue to grandstand on repeal, and that they will run on repeal again in 2012, especially if the courts uphold the consitutionality of the mandate. But when push comes to shove, given the unacceptability of the status quo and the popularity of the patient protections, they will blink when it comes to actual repeal.

17 November 2010

The Healthcare is Too Damn High

While we're on the topic of deficits:

Not to belabor the point, but if we really want to cut the deficit, neither Social Security nor Defense nor other discretionary spending is the real budget killer. It's Medicare, and more precisely, the excess growth in Medicare (and health care in general) above the rate of inflation that will bankrupt us in the long term:

(Source: CBO, 2008)

Also, for those who are confused about the "too damn high" meme, I offer this flashback to one of the more glorious parts of the 2010 election season:

The rent is too damn high:

On the Bush Tax Cuts and the Deficit

From the Center on Budget and Policy Priorities:

Note that by 2050, the debt from the Bush tax cuts alone will equal 100% of GDP.  100% of GDP. Say that to yourself slowly a few times and savor it.

Two take-homes from this:

Any Republican who claims to be worried about the deficit but wants to extend the tax cuts (which is basically all of them) is a liar or an idiot or both.

It's profoundly depressing and irresponsible that Obama is willing to even consider making the middle class tax cuts permanent. IIRC, the ten year cost of the tax cuts is about $4 Trillion (with a T), of the which the cost of the upper-class tax cuts are $700Bn. So Obama making the correct argument that we can't afford the tax cuts for the rich, but ignoring the much more pressing fact that we can't afford the rest of the cuts either. Not that it matters, since Dems have so backed themselves into a corner that they'll all be made permanent anyway.

We are governed by idiots, truly.

16 November 2010

Where's my government-run health care?

Freshman Republican Congressman Andy Harris, who was elected on a promise to repeal the Affordable Care Act, is outraged that he's going to go a whole month before his government-provided health insurance kicks in:

A conservative Maryland physician elected to Congress on an anti-Obamacare platform surprised fellow freshmen at a Monday orientation session by demanding to know why his government-subsidized health care plan takes a month to kick in.

Republican Andy Harris, an anesthesiologist who defeated freshman Democrat Frank Kratovil on Maryland’s Eastern Shore, reacted incredulously when informed that federal law mandated that his government-subsidized health care policy would take effect on Feb. 1 – 28 days after his Jan. 3rd swearing-in.

“He stood up and asked the two ladies who were answering questions why it had to take so long, what he would do without 28 days of health care,” said a congressional staffer who saw the exchange. The benefits session, held behind closed doors, drew about 250 freshman members, staffers and family members to the Capitol Visitors Center auditorium late Monday morning.”

All the more embarassing because he's a doctor, for Pete's sake. You'd think he'd have a better idea of how insurance works. Guess the dude's never heard of COBRA.  Also, it's pretty standard that this is how enrollment happens.  And it's idiots like this that want to repeal the PPACA.  Jon Chait provides the best commentary:

I think we finally have a working definition of a health insurance crisis--when a member of Congress has to go a whole month without coverage. Of course nothing's stopping him from using his own money and purchasing private health insurance in the individual market. Those onerous Obamacare regulations haven't taken effect yet so he can explore the wonders of a still-functioning private insurance market as God and Adam Smith intended.

05 November 2010

Friday Flashback - A New Threat

I wish I could say that every patient encounter worked out well, that all my patients went home happy and satisfied.   It would be nice, but unfortunately that is not true at all.   There are many patients who present with unrealistic expectations or an agenda which is non-therapeutic and I am relatively straightforward and unapologetic about correcting patient's misconceptions about the care that is or is not appropriate in the ED.  Unsurprisingly, this often, though not always, involves narcotic medications.

Which is not to say that I am a jerk.   I try to be compassionate, and I try to find alternative solutions, and I have been told that I can turn away a drug-seeker more nicely than any other doctor in the department.   But when it is time to say "no," I say "no," firmly and without evasions or excuses.

People don't like to hear that.  All the more so in this "the consumer is king" environment of customer-service culture we foster in the medical industry these days.   So, when I do say no, as nice as I try to be, some people get upset.  Sometimes they escalate.  They hurl insults, spit, throw themselves on the floor and throw a fit, or feign unconsciousness.  I have been threatened with complaints to administration, with lawsuits, with actions against my license, and even with physical harm.  I pride myself in being determinedly polite and non-responsive to behaviors like these, since, if I engage, it only further escalates the situation, and the threats are usually empty (though I am rather security-conscious both in and out of the hospital).

I thought I had heard it all, but I got a new threat recently.  The context was one in which I felt a little bad about having to say no.  The patient was a grandmotherly sort of lady in her middle years.  She presented a sad and pathetic figure as she told me her tale of ongoing diffuse body pain which was poorly controlled even on high doses of methadone.   Alas, she was out of her meds and wanted a refill (actually, her initial request was to be admitted to the hospital).   She was unable to explain how she had come to be out of her pain medications.  A quick record biopsy showed that she had many, many previous ER visits for pain medicine refills, and had been on a pain contract with her doctor, who had terminated it because of her repeated violations of their agreement.

In light of this, I felt it would not have been appropriate to provide further narcotic medicines through the ER.  She had been out of her meds long enough that she was not in symptomatic withdrawal.  She had already been referred to a pain management clinic for future care, so there was not much more for me to do.

She escalated; I explained my thought process.  She yelled, she wept, and she begged.  I held firm, and she was discharged.  On her way out she stopped by the charting station and said, with a vicious spite in her voice, "I hate you.   You are a terrible, terrible person, and I hope you suffer, and I hope your children suffer.  In fact, I am going to make sure of it.   I am going to go home and make a voodoo doll of you and all of your children and I am going to stick pins in all of them!"

What does one say to that?  Suddenly I didn't feel so bad about saying no any more.  Bemused, I encouraged her to "have a nice day" as she stormed off.

This job is never dull.

Originally Posted 6 November 2007

02 November 2010