"Hospitals Not-Profit Full"

Was Zach of 'Rage Against the Machine' implying what we're all thinking now?

How many non-profit hospitals/hospital systems truly deserve their non-profit status?

Should they be competing with the for-profit systems in the same way?

No Shows

"No Shows" are a thorn in our sides.

A recent article suggests taking the approach that the airlines take...to overbook.

Is the ideal of immediate access, no wait time, plenty of time with your physician, and quality care reasonable?

Is Primary Care Dead? And Do YOU Feel Fine?

From "Musings of a Distractible Mind":

Notice the subtle strife between internal medicine and family medicine, with the assumption that family physicians see less complex patients.

Notice that some primary care physicians are doing well...also note that this is in the Southeastern US, where reimbursement rates are higher overall.

Paging Dr. Gupta: The Anti-Vaccine Crowd is Calling

Should Dr. Gupta stimulate conversation around a controversial topic (vaccinations), or should he share what he knows (or should know) about the data?

The heated commentary sure increases hits.

Sick Visits Always Win

Even when patients come in for preventive services, their satisfaction depends on whether or not the "pain" or "illness" that they have at the same time is addressed.

So when someone comes in for a physical, many times they really have something specific they're worried about.

Do you address the preventive care, or do you address the illness?

(Or do you address both and eat the cost of one?)

If you want us to focus on wellness, you've got to pay for it....this is the bottom line.

Medicare Will Pay for "Heart Scans"! WTF?

You've got to be fucking kidding me.

Medicare has agreed to pay for heart imaging studies?

What the fuck?

Let's not pay for things for which there is clear evidence (or at least not pay adequately for them), and let's pay for cardiac imaging, for which there has been no clear impact on morbidity and mortality.

It looks like the American College of Cardiology and the American College of Radiology (along with a number of pseudo-organizations, such as the Society of Cardiovascular Computed Tomography) are our heroes here.

Of course, the rest of us know that they're behind this because it leads to more interventional cardiology procedures. One can never do enough stenting, you know...

In the meantime CVT surgeons are getting screwed, despite the fact that they've got a superior intervention....and the folks that are behind aggressive medical management are REALLY screwed.

This decision so perfectly demonstrates why complete anarchy is necessary to reform our health system. The whole fucking thing needs to be blown up:

• Incentives are skewed to benefit the high-tech proceduralists, independent of evidence.
• The average person is brainwashed to believe that they need these things.
• People get things that they don't need, and they get hurt.
• The system pays for the complications.
• There's little money left for the physicians that do the work to lower costs and improve outcomes for the system.
• Medicare's decision here leads to unnecessary testing and intervention, and thus more intervention without benefit.

How can it be possible to have true health care reform without saying 'no' to some things???

Can P4P Programs Increase Racial Disparities in Health Care?

If it meant more money for your work, would you see anyone but white men?

Racial disparities just might be enhanced by pay-for-performance (P4P) initiatives, whether or not they are intentional.

Read the article from Health Affairs.

Healthcare 2.0 and Doctor 2.0: An Interview with Jay Parkinson, MD

Is health care stuck in 1994?

Is the face of the new uninsured/under-insured changing?

How can technology help us?

What do You Call a Doc Who Spends Enough Time with Each Patient?

From Kevin, M.D.:

"What do you call an internist who spends enough time with each patient?"

Poor!

(Love the first comment..."What do you call a 50-year-old obstetrician? A gynecologist!")

Traditional Medicare is More Efficien than Medicare Advantage Plans? So Says MedPAC Chair Hackbarth

Overall, it may be true.

But the good, cost-effective, high-value Medicare Advantage plans (which often are tightly managed by virtue of a risk-sharing structure) are getting a bum rap by being lumped in with the FFS Medicare Advantage plans.

Guess what?

The fee-for-service versions of these plans aren't managed as tightly, and have more cost! It doesn't take a rocket scientist to figure this out!

From a recent MedPAC report:

"...However, most of the enrollment growth was in private FFS plans—whose enrollment more than doubled last year. Yet, private FFS plans have no requirement to coordinate care or report quality measures, and their payments and inefficiency are even greater (117 percent and 108 percent of FFS) than the MA program as a whole."

Pharmacists Help in Controlling Diabetes

At $60-$90 for a 30-minute session, I'd do it too.

Oh, but then again, I can't as a physician....I'm legally required to accept the Medicare rate (or non-rate, as payment for patient education and prevention is often denied).

The fact that the pharmacy also cashes in on the margin from selling the meds can't hurt either, huh? No Stark Laws here.

Seriously, I think anyone/everyone in the health care team must play a role in chronic disease management, so I'm happy for that. But this phenomenon is one of those un-intended consequences of a dysfunctional reimbursement methodology.

Want to Live Longer? Be White...It'll Be Alright!

Racial disparities in health care continue to be a problem.

Don Berwick has even commented on them.

In the Institute of Medicine (IOM) report, "Unequal Treatment", it's made clear that "...many people of color receive lower quality of care than whites, even when presenting with the same health problems and the same health insurance."

Why the fuck didn't the Department of Health and Human Services want to include this in their recommendations?

("Duh...Gee...I thought those people were all killed off by Katrina?")

Down with the Anti-Vaccinists!

I've said it before...

The anti-vaccinists are selfish bastards, that think nothing of leeching off of the rest of society. Belgium has taken a hard stand on this, and rightfully so, jailing Belgians that refuse polio vaccine.

Polio is a horrible disease. The World Health Organization's efforts at eradicating it started in 1988, and they've done a pretty damn good job: 99% reduction.

Both medical experts and bioethicists agree:

"...unlike other medical problems, in which rejecting treatment only affects the individual, refusing a vaccine for a transmissible disease like polio puts others at risk as well."

"Ethicists argue that people who refuse vaccinations are taking advantage of everyone else who has been vaccinated. Once the majority of a population is vaccinated, there are few susceptible people the disease can infect, thus lowering the odds of an outbreak.

People who refuse to be vaccinated are 'free riders,' Harris said. 'They can only afford to refuse the vaccine because they are surrounded by people who have fulfilled their obligations to the community.'"


So, listen up you fucking selfish dumbshit anti-vaccination cocksuckers! Just because you're rich enough to both "afford" and waste the luxury of health care in this country doesn't give you the right to potentially inflict harm on the rest of the population.

...and once and for all, despite the media bullshit, vaccines don't cause autism.

Bite me...self-indulgent assholes.

Health Care Battles: Google Versus Microsoft

Two angles on the issue here and here.

Good stuff.

2008 Election: Health Care Op-Ed Summaries

From the Kaiser Daily Report comes a nice summary of recent health policy op-ed pieces related to the election.

Virtual Bundling to Penalize Health Care Wasters

Virtual bundling to reduce payments to wasteful hospitals and physicians is likely to be coming soon from CMS.

It's a payment penalty. It's going to spank those that are inefficient and wasteful, thus depleting our precious health care resources.

I like it.

Even more, I like the concept of redistributing some of these funds to reward those with more responsible resource utilization, but only if this is not the sole variable (e.g., outcomes must also be considered if we want to ultimately reward on value).

I'm not quite sure what the "virtual bundling" concept will look like in practice, however.

Employer-Sponsored Health Care--"The Slick Pickpocket"

From the WSJ Health Blog:

Uwe Reinhardt, a Princeton health economist, likens the employer-based health insurance to a garden party where a very slick pickpocket steals your wallet and then buys you roses and chocolates. “You’d be very grateful,” Reinhardt tells the Health Blog. Employers “are pickpockets who very skillfully take it out of your paycheck. Then they say, ‘Now genuflect.’ ”

We all know this, but it's good to be reminded. Employer-sponsored health care is inefficient and ultimately is offset by salary adjustments, not typically from the profits of the organization.

Health Wonk Review Hosted by Work Comp Insider

Health Wonk Review is a biweekly summary of the best in health policy blog posts and knowledge.

Save Up $225,000 by Age 65 to Cover Your Health Costs

A recent report by Fidelity Investments predicts that a 65-year-old couple retiring in 2008 will need $225,000 to cover medical costs in retirement.

What happens if I'm not retiring until 2020?

Start saving, suckers!

Big Pharma Deals Galore

What's going to happen with big pharma?

A number of players have taken a beating. The time for deal-making is prime.

Check out the "Pharma Deal Bracket" for predictions on what might happen in terms of pharmaceutical industry consolidation.

What will this mean for consumers?

The Shit Is Going to Hit the Fan, Starting in NY

As NY Attorney General Andrew Cuomo subpoenas health plans including Aetna, Cigna, Empire Blue Cross Blue Shield, Excellus, UnitedHealth, WellPoint, and the combined GroupHealth and HIP Health Plan, what will be uncovered.

He's serious about this. He's even requesting all email correspondence at the senior levels of these companies (CEO, CFO, COO, Presidents, as well as employees that supervise the claims process).

What started this? Here's the gist:

• Ingenix is a company that provides the data to help insurers determine rates, including out-of-network rates.
• United Healthgroup owns Ingenix.
• There is suspicion that United Healthcare and other insurance companies may have colluded with Ingenix to manipulate the data in a way that benefits them and hurts consumers (for example, the rates may have been set artificially low for out-of-network reimbursement so that the patient's out-of-pocket portion is much higher).

You might say (or I might say) that this is what you get when you turn health care into a for-profit industry.

But I don't accept that conclusion--bullshit. Business ethics is the fundamental problem, and although companies like Enron took center stage, corporate responsibility needs to be more important across the board.

Let's just say, I'm betting that the shit's gonna' hit the fan. Let's hope I'm wrong.

General Surgery is Getting Fucked Over as Much as Primary Care

When you can make more from stripping veins than you can from taking out half of someone's colon, something is really fucked-up in the system.

General surgery is the primary care/generalist equivalent among surgical specialties. And they're getting fucked over just as bad.

No wonder we're looking at a shortage here too.

Calling in a Prescription or as Ass-Kicking

This story about a request to call in a prescription is all-too-familiar for many of us.

The best part of this post is the first comment, "It's a shame that you can't call in an ass-kicking for all involved..."

Healthy, Nurtured Kids Lead to Less Crime

Great posts from Health Beat:

Part I and Part II.

Here's the deal. Keep kids physically and mentally healthy, and they're less likely to commit crimes as adults.

Top 10 Health Affairs Blog Posts

Health Affairs kicks ass.

Here are the top 10 posts from the Health Affairs blog.

"I'm Not Fat, I'm Just Big-Boned"

Guess what?

Cut down on TV and computer use, and your "big-boned" kids will magically be right-sized.

American Well: This is Cool Shit

Next phase of interacting with patients online.

Excessive CT Scans and Imaging Cause Cancer

Or at least increase your risks of cancer.

A recent study showed that the average trauma patient receives a workup that delivers about the same amount of radiation as 1,005 chest x-rays.

McCain Believes Vaccines Cause Autism! WTF??

And by the way, he thinks the world is flat too.

Vaccines absolutely do not cause autism, you frickin' moron!

This Week's Lottery Winnings: Access to Health Care!

True story from Oregon.

The Reason for Slow EHR Adoption

From the Baltimore Sun:

"One key is incentives. For an individual doctor or a small practice, switching from paper to digital costs between $40,000 and $60,000. For most doctors, this is a lot of money: The average physician pulls in about $150,000 a year. And the savings from going digital mostly accrue to the insurance companies, Merritt said.

'There's no incentive to adopt the technology,' Merritt says. 'No one helps them offset these costs.'"

Yup.

Fuck It...Who Needs Oxygen?

One way to reduce costs is to stop paying for oxygen 13 months after discharge.

Fucking rocket scientists in the Bush administration....

(Especially, because we all know how expensive oxygen is!)

Medicare Cuts Reimbursement 15.4% on 1/1/09

Don't fix the formula, and here's what you get.

(P.S., It'll be handled through the veil of efforts to improve quality and efficiency, with measures that place the burden for this on primary care physicians, without requiring tighter management of specialty referrals and procedures.)

Cap the Greedy Bastards, and Use the Money to Fund Mental Health Parity

Yeah. I'm for this bill.

1. Limiting the number of physician-owned specialty hospitals and ambulatory surgical centers will definitely reduce the number of unnecessary procedures being done in these places.
2. Mental health has been screwed over for way too long, and the lack of mental health resources ends up shifting costs to the medical side...health care costs go up without mental health treatment.

Even thought they're cheaper, I'm not convinced that they are safer or provide better service.

(FYI...the limits would protect my dumb-ass colleagues that continue to invest in these despite the fact that there's an oversupply in most markets.)

Fucking Airborne...I Tried to Tell My Patients It Didn't Work...Oh Well

Liars and cheaters, watch out. Take a lesson from the makers of Airborne. $23 million is quite a lesson.

More Expensive Pills Work Better, Right?

This MIT study suggests that a placebo at $2.50 per pill relieves pain better than one priced at $0.10 per pill.

Incidentally, it looks like the same is true for wine--the same wine priced more expensively tastes better.

My ass hurts just thinking about the larger macroeconomic consequences of this conclusion.

Good luck explaining cost effectiveness to these folks.

Rich Whining Docs Fight...Health Care Implodes

Check out this rant between the ER docs and the sub-specialists.

Where's the love?

(And do they realize that there are docs even further down the economic totem pole for whom it's not a matter of how much you can make, but rather one of staying in business or not!)

International Health Charity Fills Need in US

Believe it.

Remote Area Medical typically serves those in desperate need of health care in developing countries.

It turns out that there's a huge need here at home.

Their recent weekend outreach in Knoxville, Tennessee treated almost 1,000 people in need, and had to turn away 400 due to the overwhelming response.

I'd hate to see how bad it needs to get before we do something meaningful in health care reform, instead of the watered-down versions in some places (Mass, Colorado).

FDA Wants More Power

Give the FDA more powers?

Nah...fuck it. I'm against big government.

By the way, I also like shit with my beef, maybe even served with a side of Creutzfeld-Jakob Disease. Prions...mmm.

Should Universal Coverage Even Be an Item on the National Agenda?

Some people don't think so. Check out the article in the NY Times here.

Why Winter is Flu Season

Even docs wonder about the reasons why flu season takes place in the winter.

Personally, I think there are a number of reasons. This recent study adds to the list.

Cool stuff.

(Think M&M's.)

Dumb Ass Thinks We Shouldn't Vaccinate Against Influenza

The problem with the mainstream media is that it's so fucking biased.

I'm glad people are reading. I'm pissed off as hell that the media is feeding information that leads people to make bad choices.

Health Punk spanks someone on ABC's reader comments.

Anatomy Lesson: The Anus from Mianus

Learning can be fun, especially in Mianus, CT.

A New Market for Occupational Medicine...in India?

Check out the problems with repetitive injury that employees at outsourcing firms in India are now dealing with.

We're outsourcing more than we think.

Who Needs Evidence? There's Money to be Made!

Look at this irresponsible campaign recommending that people demand a CT scan.

Bullshit, bullshit, bullshit.

It's enough that this racks up waste and cost in the system. In fact this does actually does harm!

Shame on the oncologists that support this...but then again, since when is oncology evidence-based? There's money to be made!

Flu Shots and Autism? Dumb Asses.

People are so frickin' stupid sometimes.

The CDC recommends flu shots for all kids now.

This story says that parents disagree.

The reasons are bullshit, by the way. Let me clear this up:

• Vaccination does not cause autism (and "Dr. Bryan Jepsen" can't be a real physician--nor an autism expert--base on his suggestion--quackery in mainstream media).
• The vaccination isn't just about protecting kids (the pediatrician interviewed doesn't seem to get this fact either)--it's about preventing it from spreading to the high-risk groups (the elderly, those with chronic diseases, the immunocompromised, etc.) for whom it really is deadly on a wide-scale basis. A great example of selfishness ("it's all about me") in our society.

No Ads on Google Health? How Do They Make Money?

Here's how.

Bring Back Managed Care to Revive Massachusetts Plan

Align incentives to reward people for keeping patients healthy?

Capitation?

Really?

Duh.

Medicare Advantage Plan Spending

"Of the monthly per-beneficiary payments to MA plans, 87% is used for medical expenses, or $683 of $783 per beneficiary per month, according to the report. About 9%, or $71 per beneficiary per month, is used for nonmedical expenses, including administration, marketing and sales. About 4%, or $30, is considered profit, the report found."

Read the Kaiser Daily Policy Report here.

Let's Just Kill the OB's

Can you frickin' believe this?

They want to raise ob malpractice premiums even more in NY?

Oh Shit. Bad News for Health Care Finance. Worse News for Health Status and Homelessness

Two graphs, one depicting trends in earnings, and another showing trends in housing prices, just might hint at what's in store...

(Never mind the fact that these folks are on a runaway freight train to homelessness and piss poor health status.)

10 Out of 10 Pain?

10 out of 10 pain apparently means different things to different people.

Suckered by the "Popes of Cardiology"--LDL is Bullshit?

Have we been suckered by the "Popes of Cardiology" (who have also made a bundle of cash in the process)?

Could it really be true that LDL cholesterol is bullshit? That LDL values should be ignored?

I just read two kick-ass posts from Maggie Mahar at Health Beat.

Check out The Cholesterol Con Part I and Part II.

Yes. Health Care IS a Dysfunctional Market.

Yeah, yeah. We know health care is a dysfunctional market.

The consumer doesn't know the cost (or quality, or value) of the services they receive. They're also distanced from directly paying for the services. Physicians, nurses, attorneys, and everyone else attached to this dysfunctional system, in general, can waste resources without an immediate direct impact.

Of course, we know that this is a huge reason for overspending in health care.

Now stop fucking whining and do something about it. All the whining is boring the shit out of me. All of my own whining is boring the shit out of me, for that matter.

Skin Color is Often the Most Important Predictor of Survival

RWJF on Thursday released a report that looked at how education, income, race and ethnicity play a role in health. Findings include:

• Blacks are more likely than whites to die from many health conditions, such as diabetes, heart disease and cancer (Hille, Washington Examiner, 2/29);
• Residents who have not graduated from high school are more than four times as likely to have poor or fair health than college graduates;
• College graduates on average live five years longer than residents who do not graduate from high school;
• Higher-income residents on average live two years longer than middle-income individuals; and
• About one in three lower-income residents has a chronic disease, compared with about one in 10 higher-income residents.

Warning to Medicare Advantage Plans: Watch Out!

Looks like CMS and Pete Stark have these plans in the cross-hairs.

It's true that the FFS/PPO versions of these plans have much higher costs (and much higher profit margins for health plans). I just hope that the more tightly managed HMO versions don't get hit.

Death Most Likely Outcome of a Code. Same at 30,000 Feet.

We know that if you code, the odds are against you.

Seriously, the survival rates for when a patient's heart stops in a hospital suck.

What the hell do you think the stats will show when it happens on an airline at 30,000 feet?

Screw it, let's just sue the airline when the inevitable death occurs.

Our society has such frickin' unrealistic expectations. Sheesh.

I Love to Menstruate, Don't You?

Check out Annuale, the new oral contraceptive that allows for once-a-year menstruation.

Nader and Single-Payer

Yes, he's running again.

And he's very clear about differentiating himself from the other candidates via his support for single-payer heath care.

Google Health and Cleveland Clinic--Hell Yeah!

Google and Cleveland Clinic are teaming up to create a personal health record (PHR) quicker than anyone else could hope.

PHR's from our perspective are very important.  The fact they are patient-centric is huge.  The fact that they are portable and can be viewed outside of the walls of just one clinic is extremely valuable, and ultimately saves lives by reducing the likelihood for medical error.

(If you live in Cleveland and, by chance, are somehow rendered unconscious and taken to an ER in Lincoln, Nebraska, the fact that the physician can access your information completely dramatically increases the likelihood that you'll survive.)

We've had the technology to do this for a long time, but so many people haven't had the balls to move forward.  These companies have been fearful of the potential problems associated with HIPAA, and have either chosen to rack up legal fees in the process of creating a watered-down version of their initial idea, or have abandoned the idea completely.

Google has balls.  And although I didn't realize it, Cleveland Clinic seems to have balls too.

I like it.  

HIPAA hasn't been tested in this fashion.  When a law is created, it's also important to test the legislation based on real-world scenarios.

Do something remarkable, and worry about the impact later.  This is an idea that kicks ass, that is revolutionary, and that is in the best interest of all of us.

Privacy is important, but not to the degree that people get hurt.

More commentary on The Health Care Blog...

Single-Payer versus Universal Health Care--Graham vs Porter/Teisberg

Single-payer options have a lot of merit, from both an economic standpoint and from the standpoint of moving towards a healthier society.

Check out this fantastic single-payer animation (which apparently was done by a doc while still in school).

My only adaptation of a single-payer approach would be that any such approach much ensure adequate competition, as discussed in more detail by Michael Porter and Elizabeth Olmstead Teisberg in their book Redefining Health Care.

In their book, the authors do conclude that traditional single-payer approaches can't/won't solve our problems, but state that the reasons for this are based on the assumption that a single-payer solution will eliminate competition as it has in other countries.  My take is that single-payer health reform and competition are not mutually exclusive.  We have an opportunity to learn from the weaknesses in other single-payer systems, and have experience from the polar opposite to design a "single-payer 2.0" option.

However you feel about single-payer, the authors provide a very nice and very thorough description of why universal coverage is essential to solve our problems. 

Homeopathy is a Fraud...Like Cures Like? WTF?!!

Homeopathy can't cure HIV.

It's a shame that insufficient access to legitimate care is leading people in Africa to seek care from homeopathy.

It's criminal, deceitful, and downright sinister.

(Homeopathy can't cure anything, by the way. It's all bullshit designed to milk money out of people when they are most desperate by relying on the placebo effect. Fuck them, and fuck everything they stand for, the unethical bastards).

Coverage without Access is Meaningless-Gov Crist Proposal Falls Short

Like I've said before, you can expand coverage to win points with your supporters and to get elected.

Medicaid provides coverage. But nobody wants to accept Medicaid...they can't survive if they do.

Nobody is talking about reimbursement rates and how mandated coverage will affect these rates.

Governor Crist's plans are no different.

What a Fuckin' Shame...Katrina Still Haunts Us

Katrina's a fuckin' bitch.

Katrina was and continues to be a bitch.

But it goes beyond the initial death and destruction she caused.

She surfaced issues about race, about corruption, about choices in federal spending (or underspending), about media lies, about the facade that makes us think we're safe and protected by our government....and of course health care.

Mental health issues, stigmatized and under-treated, carry huge cost and societal burdens. And mental health has been underfunded (and has also had shameful access) for a long time.

This has been true for a long time, and it's also very true (magnified 10x) in New Orleans.

Bitch. I wish I could have ignored the problem...

Strong women get a bad rap. They raise issues that the rest of society doesn't want to deal with. They take a stand. They are accused of being unwomanly. And they know their shit. And society calls them "bitches".

Let's fucking listen for a change.

Clinton vs. Obama

Screw mandates....they don't work for a lot of reasons.

But in this brief Clinton vs. Obama excerpt, she's right from an economic/actuarial standpoint (and a health care spending standpoint) on what happens when not everyone participates.

You get adverse selection that hurts everyone that does.

Tying Pharma Rep Income to Outcomes?

Could it actually happen that pharmaceutical rep income will one day be tied to patient outcomes or health status within a territory?

Suck It, Health Net: No More Retro Cancellations

Looks like the recent $9 million decision against HealthNet (which was no where near a prior $89 million decision) was enough to get the CEO to declare that they'd be stopping retroactive cancellations immediately.

Good outcome, and right thing to do from an ethical/integrity standpoint. If you accept that our society has made a choice to opt for for-profit health care coverage, it still doesn't mean that those for-profit entities don't have to abide by commonly accepted business ethics.

If I enter into a "bad deal" as a company because I've not scrutinized the deal properly (e.g., shoddy underwriting in this case, one could say), then you have to live with the outcome of your decision. Changing the rules later flies in the face of business ethics.

You can bet, however, that they're going to tighten up their underwriting process a whole lot at the same time, and that it'll be a lot harder to get coverage.

My Point: Before we all rejoice in this decision, however, count on the fact that HealthNet will be tightening up their underwriting mechanisms a lot...and fewer people will be covered as they are deemed to be a "bad deal" business-wise.

Natural outcome for a for-profit process.

Want to Combat Retail Clinics? Strike While the Iron's Hot!

The public is still testing the waters on retail clinics.

I can't blame them. "Rollback Prices" are great, but what about when they apply to your health?

In any case, this WSJ article reinforces the fact that the timing may be just perfect for physicians to reinforce their differentiation. (Beyond "we get more than 2 weeks of anatomy"!)

It's actually probably worth a small premium...creative scheduling in traditional primary care practices to offer extended hours, combined with clear & concise pricing brochures could be all it takes.

In any case, just remember that timing counts.

Arrgh! Fuck the RUC!

More on this bitch of an organization from Kevin, M.D.

Read the full piece on the RUC in Family Practice Management here.

Do you think 5 caths (assuming they are actually necessary) should be equal to 80 99214's?

Canadian Health Care Has Too Little Rationing

Canadian health care is not socialized medicine (as I've said before).

It's a single payer system in which there is too little regulation.

In fact, based on my experience in both systems, there is a lot more rationing in our private-based health system. We've got formularies, prior authorizations, referral management, utilization management, tiered copayments, deductibles, different costs for in- and out-of-network utilization.

The Canadian system doesn't have most of that.

Until now. Quebec is considering instituting a co-payment. I think the time is ready for a change in the Canadian constitution to allow for even a nominal co-pay (I actually was surprised to see the $25 amount proposed).

Quebec actually does better in terms of utilization than other provinces.

Just imagine what takes place in provinces such as Newfoundland or New Brunswick, and what would happen if a co-pay were introduced!

In any case, just realize that the Canadian system has problems, but these are actually due to the lack of sufficiently aggressive resource management.

I feel the need to pound it into people's heads that this is not an issue of the system being socialized, nor is it a matter of the system needing the $25 to directly offset costs. It's more to reduce unnecessary utilization.

Natural evolution. They'll do well with this.

More Fucking with the Candidates...Just 'Cause

In the mood to fuck with 'em? Just read this kick-ass WSJ op-ed piece.

More Cardiac Arrest Deaths at Night & Weekends

You are 18% less likely to survive a cardiac arrest in a hospital if it occurs on a night or a weekend. Huh.

I'll make sure I don't.

How Physicians are Paid: More on the SGR Problem

Check this out....another post on the problems with the sustainable growth rate formula used by Medicare.

I'd definitely take your time reading this because it's great insight into how physicians are paid, how the SGR creates incentives for the wrong things, and how to fix it.

The Biggest Predictor of Longevity Is....

Race.

Ask Don Berwick.

Now the a report from the American Cancer Society says the same.

It's more than economic factors, since the same pattern is seen in insured minorities versus insured caucasians.

No...racism doesn't exist anymore.

How to Really Keep Health Care Costs Down

Health care is apparently cheaper if you just let the poor bastards die...especially the smokers and the obese.

We should applaud them. If you choose bad habits, after all, it's better for the rest of us because you die faster. Hell, let's give them free cigarettes, beer, and sausage....unlimited.

What a great fucking strategy.

Sick people cost less because they don't live as long. So if we convert this to an equation and solve to maximize variable X, where X = health care savings, we're better off just letting people die sooner.

Clap.....Clap....Clap.....

BRAVO!

These Dutch researchers are so frickin' brilliant!

Seriously, though, I wonder if the same would be true in the US, where we actually ramp up resource utilization exponentially in the last 6 months!

"Do More Harm": The Trends at the End of Life

A friend of ours found out their dog had severe osteoarthritis of the hip. The vet suggested that he could either give the dog a hip replacement (at a cost of approximately $5,000) or euthanise the animal for a much lower cost. Our friend really loved his dog, so he opted for the surgery.

The dog actually recovered pretty well initially. It appeared the pain was manageable, and the dog was starting to move around more easily. A week later, however, the dog was acting listless and appeared to be breathing rapidly.

Our friend took the dog to the vet, and the dog was diagnosed with pneumonia requiring treatment with IV antibiotics and another inpatient kennel stay.

The cost of this stay, including x-rays, etc. was about $800.

The dog went home, and had diarrhea everywhere. It quickly became dehydrated and died.

Was suffering, multiple hospitalizations, and ultimately death...with a lot of expense for the owner...ultimately worth it?

Our friend was paying for the bills out-of-pocket, of course. What about if someone else were paying for it?

It has been said that the majority of an individual's health care costs are spent in the last six months of life. It has also been said that this doesn't correlate with a better quality of life during this time.

If this is all true, why don't we have the guts to talk about it?

Time to Fuck with the Candidates...Because It's Our Job

When I woke up this morning, I knew it would be a great day to fuck with the candidates.

The candidates are getting more detailed in what they're willing to share in terms of health care reform.

For both democratic candidates, reform is a priority "...with the stated goal of providing coverage for everyone."  Yeah, yeah.  We get it.  I like it.  But is anyone thinking about funding?  Everyone wants to maximize their share of the health pie.  What happens to access if we don't have any statement about funding and how primary care reimburesements will have to increase?  (What about rationing?  If anyone has a way to do this without rationing, I'd love to hear it!)

The republican candidates want reform too (if you don't, you won't get elected). If we just make health care more affordable for the uninsured by providing "...subsidies to help people with modest incomes buy health insurance." Yeah, like that's going to change spending patterns. We know that people tend to decline coverage options via their employer if it involves even modest outlays--it's because they're deciding about covering costs of living and making mortgage payements. You can't blame them for making the same choice. So this solution is worthless (mandates don't work, either, by the way).  

Huckabee's just a fucking joke when it comes to healthcare....the article I linked to just sugar coats it.

The biggest potential challenge with all ideas is that unless everyone has to participate in the same risk pool, (or at least in geographically distributed risk pools that each require everyone to participate), then there will always be selection bias.  Sicker and "less desirable" patients from the standpoint of impact on medical loss ratio will have no choice but to migrate to these defaults.  The healthier (wealthier? white?) individuals will also self-select.  Anyone who thinks you can manage a risk pool with having sufficient healthy patients (low-utilizers) in the pool is smoking crack.

Regarding the republican candidates' proposals, how the hell can you decrease insurance industry regulations and also ensure that selection bias doesn't take place in terms of who's "insurable" and who's not?  The "who's not" category would be less profitable, and thus less insurable.  Even if you don't link premiums to health status, there are clearly ways around this.

Regarding McCain's tax credits, $2,500 for an individual and $5,000 for a family won't cut it.  Seriously, $5,000 for a family?  As it currently stands, my family would burn that up in 6 months (I contribute a portion to my employer's coverage).

Pessimistic...yes.  I think there's still a very large commitment to the future success of the health insurance industry.

"The candidates also have largely sidestepped the hard choices and tradeoffs that many economists contend will need to be part of any significant health care reform.

That includes the pending fiscal collapse of Medicare, projected to be insolvent by 2019."

In any case, I'm definitely glad that health care is taking center stage in this election.  I'm also glad that the candidates are getting to a level of detail that can lead to good debate.

But just in case you were wondering, I think we're fucked for a little (?) while.  Not enough pain yet to motivate action.

The FDA Struggles: More Proof that You Get What You Pay For

The FDA is taking lots of heat these days. Yes, it's because they screw up a lot.

But before you go pointing fingers, just take a minute to remember that budgetary choices have unintended consequences.

The strain of the ongoing war in Iraq has led to cuts in a lot of areas, and the FDA also got hit hard. Unintended consequences--they approve the wrong plant in China, not to mention the stumbles around drug safety and approval.

Just realize that there will be much bigger unintended consequences of the proposed cuts in healthcare over the next few years?

You get what you pay for.

Drug Seeker Stories...and a Vagina Story for Kicks

I always wonder why docs get so worked-up by drug-seekers.

Why not just fuck with 'em by being honest and direct?

(For the non-physician readers, we really do get these stories--so often, in fact, that it's hard to remember them all. We do want them to get better, but the first step (seriously) is to confront them on the lies they tell others and themselves.)

Never mind the misuse of resources....PandaBear is an ER doc, remember.

Health Care Competiton in The Simpsons

So, I started this post just looking for a picture of my hero, Dr. Nick Riviera.

But in the process, I found and learned so much more.

In an insightful piece published in the Canadian Medical Association Journal in 1998, two physicians analyze the medical care received by Homer J. Simpson and his family.

Which is the better physician, in terms of balancing cost and quality, Nick Riviera, or Dr. Julius Hibbert?

Oh, who the fuck am I kidding?! I don't care. Dr. Nick kicks ass.

Read the CMAJ article comparing these two physicians for the Simpson family here.

Got Weed? ACP Statement on Medical Marijuana

The ACP made a pretty strong statement regarding its position on medical marijuana, and debunked a number of myths and misperceptions at the same time.

Happy Ending to OHRP Checklist Story

The "....ragtag band of committed clinicians and other quality improvers..." has made a difference in changing policy in the OHRP regarding the use of checklists....says Bob Wachter.


Blog on.

Raise hell.

Do something.

Food Safety? Another Beef Recall!

What the fuck is going on with the safety of our food...particularly meat?

I'm not a vegetarian, but I can't believe how often we hear about beef recalls related to safety problems in slaughterhouses.

In this most recent case--the largest beef recall in history--potentially ill animals were not reported to the veterinarian, once initial inspection was passed.

Yes, there are process failures. Whenever a process fails, it's important to look at the contributing factors. Is it greed? Or is it that economic incentives in the industry are similar to what many physicians (especially in primary care) are having to do by increasing volume to make ends meet? We tell our docs upon hire that about 25 patients/day is what it takes to break-even at most of our locations. We've got some docs that see an average of 40 patients/day due to the fact that they've got some pretty significant personal financial stress going on.

Modifying incentives to avoid "cutting corners" is absolutely essential for us.

As far as the incentives in this beef recall case go, it appears it's too late, however, since much of this meat in question has likely been consumed I by now.

Oops.

Insurance Companies: No Business Argument for Quality

In a recent article, Ezra Klein says it like it is regarding why it would be poor business for insurers to compete on value:

1.  When we want insurance, we go through an underwriting process.  What's really happening here is that the insurer is trying to evaluate the value of "the deal".  They want to, like any rationally-operating business, secure profitable clients, and avoid those that are unprofitable.  

2.  Don't get pissed off.  Or do.  I don't really care.  The issue is that this is what you get when you throw healthcare coverage completely to the private market.  It must operate effectively as any other business would in this environment.

3.  Good quality in managing chronic diseases may actually end up attracting more of the "less profitable" type of customer--those that use more resources than those that don't have the disease state.  Bad business deal.

4.  In addition, the more sick people you insure, the more healthy people you need to offset this.  But in order to insure these sick people, you also have to raise premiums.  Raising premiums will ultimately scare away the healthy and more profitable patients.

In this structure, there isn't a business argument for quality.  

Ezra Klein's article also discusses some ways to get around this--avoid risk-pool selection bias, acuity-adjust funding (such as in Medicare Advantage), etc.

AMA Banned from Hearings: I Don't Care

Here's the deal.  The AMA has been banned from the hearings dealing with the impending 10.1% Medicare cuts will happen or not.  Apparently, they've just pissed people off.

I don't care.  I've always felt the AMA sucks ass, and that it could never adequately represent me and my colleagues.  In fact, if they were involved in these hearings, I still believe that they more strongly represent subspecialists.  

The AAFP and ACP got it covered, among a number of other good organizations.

With that said, I really hope they can achieve a complete formula fix instead of another patch. 

God help everyone on Medicare if they don't.

Does Preventive Care Save Money?

OK, the perspectives piece "Does Preventive Care Save Money? Health Economics and the Presidential Candidates" does raise an interesting question. 

In this case, the authors have raised the question based on the hypothesis that the statements and claims being made presidential candidates are perhaps a bit too broad.

Maybe.  I actually think this was a pretty crappy article overall...I get the point.  But it really trashes prevention in the areas where there are huge savings (brushing over the economic impact of some high-impact USPTF recommendations).  I also think it doesn't go far enough in telling the hard truth for docs and the public:

• Not all "screening tests" currently in use meet the criteria for ideal screening tests.  
• Screening tests should be use appropriately.  The authors say that "...screening costs will exceed the savings from avoided treatment in cases in which only a very small fraction of the population would have become ill in the absence of preventive measures."  Well, then, this doesn't quite meet the criteria for the ideal screening test.  The 80-year-old man doesn't need a PSA, and his wife doesn't need a pap smear.  Similarly, people shouldn't be ordering CA-125 tests for women to screen for ovarian cancer.  Strap on some balls, and tell your patient they don't need the tests.
• The public tends to think we have the ability to detect anything early and cheat death if it's caught early.  As a society, we need to get a grip on our mortality, and on what is and is not possible.
  
• The concierge physical market isn't doing any favors here.  Lots of high-cost tests without proven outcomes set the expectations for all patients that they need these things when, in fact, they may actually cause harm
  
• People need to be clear on the definitions of primary care and prevention.  Yes, prevention is part of what we do.  But it's not just prevention of heart disease, it's also prevention of the avoidable ER visit or hospitalization.  Access to primary care is clearly tied to reductions in these areas.
  
• Everyone is dancing around the fact that we'll have to ration resources more.  No, Mr. Johnson, you can't get a fucking MRI for your back given your symptoms.  And no, you can't fucking sue me for saying so.  (OK, so the candidates are just trying to get into office right now...but someone's got to be saying it!)

The authors actually provide some misleading information.  Although they didn't list the 279 preventive measures that they refer to, the authors do present some of the measures used in their tables.  The quality of some of the studies used for the analysis is really shoddy.  Take the "high" versus "low" intensity smoking relapse-prevention programs, for example.  The high intensity program sent 7 mailings to patients, while the low intensity approach sent one single booklet.  First of all, neither approach works that well!  If it were to be compared to a more effective approach (regular access with a primary care physician, support groups, etc.), I wonder if the results would be different.

And screening for medium chain acyl-coenzyme A dehydrogenase deficiency in newborns?  Since when is that a useful screening test worthy (in terms of ideal screening test criteria) of application to all patients?  I think the real issue here is that when it comes to babies, people have a real hard time rationing care (not to mention the medico-legal pressures).

It's not a horrible article.  It raises a point.  But don't fucking dance around the issues.  This is a perspectives piece, and some leeway is allowed.  We're not doing the public any service by sugar-coating the real issues.