Health Care: Is It Rationing or Is It Rational

One of the best essays I've read in a long time. I agree with it 100%.

Dissecting The Economics Of Self Referral and Playing That Board Game Known As Medical Necessity

I recently wrote a post about a being asked to do a preoperative evaluation on a healthy 34 year old pig farmer I felt was unnecessary. The request came from another physician who had a PA written level 3 H&P done three hours previously. I felt the request was medically unnecessary. However, I concluded that the patient's private insurance would pay for my consult because it met the 3 R (request, reason, response) requirements of consultative services. A reader suggested that I was part of the problem for providing a service I felt was medically unnecessary.

jcmd Yesterday 04:43 PM

So your opinion on medical necessity is irrelevant??? Wow. You just do the consult whether the patient needs one or not... You are not the one writing the checks??? What happened to your Medicare National Bank? You have shares in that bank as do I. I guess this exactly like a proceduralist doing a heart cath or a knee scope or fill in the blank when they don't think it is medically necessary... You are just selling another widget... AND complaining that your widget does not sell as highly as the other guys.

My position on that is it doesn't matter whether I think a service is medically necessary or not. Medical necessity is an insurance concept used to determine payment of services rendered. It is not a medical issue. I am not being asked a question by a surgeon to determine medical necessity. I am being asked to evaluate a patient for pre operative stratification.

I have no idea what the surgeon knows. For all I know, he is so ignorant on the risk stratification of his own healthy patients he needs an internist for everyone. The same issue occurs with consult requests between different specialists and subspecialists all the time. When an internist asks for an orthopaedic consultation on a shoulder dislocation they are requesting the consult either out of laziness, fear or ignorance. When an ENT doc requests an internist for management of stable diabetes on pills only, they are requesting out of laziness, fear or ignorance. The judgment of medical unnecessary is a judgment from those with knowledge about those who may not have that knowledge.

That's why I suggest fee for service rewards those with less knowledge and penalizes those with more because everything gets paid for regardless of how little or how much you do. This is why I am a huge fan of bundling care to reward those that practice great medicine and take care of their own risk stratification or their own stable diabetes instead of costing $250 for another doctor to take over.

The reader goes on to suggest that my willingness to do a consult I think is medically unnecessary is the same as the self referring practices of doctors doing procedures. I think that statement is completely false. Both add unnecessary cost and drive health care inflation. That's true. But in the first case, I have no way of knowing what the baseline intelligence of the doctor is. Whether they are requesting the consult out of laziness, fear or ignorance. In the self referral game, the doctor knows their threshold for all three. And they can use that to their advantage AND benefit through unlimited self exploitation to those ends. Because Medicare pays every time. Because everything will always be medically necessary. That's the nature of our fee for service.

That's why I think the medical necessity threshold for payment is a scam resulting in uncontrolled health care inflation. We doctors order the tests for just about everything. We are a big part of the problem in health care inflation. I read once, and I can't find the source, that Medicare denies claims based on medical necessity close to ZERO percent of the time. Either doctors are always right or medical necessity simply cannot distinguish good care from more care.

Take for example this article on MSNBC this morning regarding rates of CT scan utilization.

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In August 2005, doctors at Urological Associates, a medical practice on the Iowa-Illinois border, ordered nine CT scans for patients covered by Wellmark Blue Cross and Blue Shield insurance. In September that year, they ordered eight. But then the numbers rose steeply. The urologists ordered 35 scans in October, 41 in November and 55 in December. Within seven months, they were ordering scans at a rate that had climbed more than 700 percent.

Do you think they suddenly had sicker patients? Do you think a major study came out to change the practices of Urologists everywhere? Do you think the entire group of doctors lost a lawsuit that created defensive medicine?

No. They bought a CT scanner and self referred their patients to their own equipment. And I'm sure every single one of those scans will be paid for because they will always be medically necessary.

I despise this type of self referral practice because I know someday I will be a patient as well. And I hate to think, knowing what I know, that doctors will do stuff to me that generates profit instead of practicing right medicine. Will they operate on me or image me or stick catheters in me because they can? I can understand ignorance. If they do it out of ignorance, they should be punished by making less money, not more. That's what bundled care will do for you as a patient. If they do it out of fear, they should spend more time with their patients explaining the risks and benefits and doing what the evidence says they should. We should not pay for the fear of others. If they do it out of laziness, they should be paid less for their care. That's what bundled care will do for you as a patient. If they do it out of greed, they should not be rewarded with more money.

You can make profit and practice good medicine by reducing the cost of care for everyone. That's what bundled care can do, if it's paid for with algorithms that encourage evidence based practice and encourages efficiencies of scale and lets the doctors decide the most efficient and cost effective way to deliver the right care. Right now in our fee for service model, everything is always medically necessary. Nobody has any incentive to think and think well. The easiest way is often the most expensive. Our ability to provide quality care, for the masses, comes at an expense that is neither rational nor sustainable. Something must change in the way we offer care before nobody can afford any of it.

I think the solution comes in bundling.

Is It Unacceptable To Expect Negotiated Rates In Government Run Health Care?

With regards to a compromise by Blue Dog Democrats on setting the rates for paying doctors:

Waxman's committee resumed work Thursday, with the goal of finishing Friday, after a week-and-a-half delay caused by objections from fiscally conservative Democrats. That rebellion was quelled with an agreement Wednesday that would protect more small businesses from a requirement to provide insurance to their employees, and restructure a new public insurance plan so it could pay higher rates to doctors and other providers, among other changes.

What did the the other Democrats have to say about that?

"This agreement is not a step forward toward a good health care bill, but a large step backwards," 53 Progressive Caucus members said in a letter to House leaders Thursday. "Any bill that does not provide, at a minimum, for a public option with reimbursement rates based on Medicare rates -- not negotiated rates -- is unacceptable."

Let me get this straight. In a world where Medicare and Medicaid pays less than cost, these Democrats want an option where doctors have the opportunity to lose money for every patient they take care of? If negotiated rates are unacceptable, exactly how is the Medicare rate acceptable. There is a reason why many Medicare and Medicaid beneficiaries cannot find a doctor to take care of them. Because the non negotiated rates are unacceptable.

Perhaps our Congressmen and women would like the 300 million Americans to take a yearly vote on the value of their service to this country. No negotiation. Majority salary wins. You just may not like what your constituents are offering you. And you just might quit. How's that for unacceptable.

This Is Why County Fairs Can Be Scary

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It Might Be Time For A Blog Break When

You check out with the hospital operator by saying:

I've checked out to Dr Wes.

The Science Of Extrapolation

Offering a therapeutic plan to 92 year olds with metastatic breast cancer because the data on 40 year olds suggest a bias towards this outcome benefit or that outcome benefit is like waiting a few months to get a bulk rate on your wedding cake. The extrapolation of data is inappropriate. We have no way of knowing whether the data for doing nothing would show a survival benefit or not. It's the equivalent of offering her chiropracy. Both are believers in their therapy.

If there are any oncologists reading this, I am more than open to some CME on the matter. Do you have compelling evidence that offering therapeutic intervention to 92 years olds in this situation has a survival benefit over doing nothing?

via Cases and Images Blog

Have You Ever Seen A Cardiologist Do A Paracentesis?

So I'm talking to my brother one day. He's a cardiologist. He tells me about a patient he once saw that was admitted to the cardiac specialty hospital with massive ascites, abdominal discomfort and a diagnosis of acute heart failure (thus the heart hospital admission). He called me up and asked me how to do a paracentesis. I asked him why he was even thinking about doing it. He said he was told the GI guys don't do them. That the GI guys will usually recommend a general surgery consult to do the paracentesis ( I can only ponder why).

I laughed. That's hilarious. A general surgeon for a paracentesis? I asked why the interventional radiologist just doesn't do it. Politics he says. They almost never come over.

I'm not sure which part is funnier. A general surgeon doing a paracentesis at a heart hospital or a cardiologist doing a paracentesis at a heart hospital. It turns out the hospital doesn't even stock the paracentesis kits. To do one, he would have to jimmy rig a make shift MacGyver kit by combining certain aspects of the pericardial needle and thoracentesis apparati.

I told him to be careful about doing the paracentesis himself. Not because he might miss the 10 liters of fluid bursting through the pregnant man's belly. But rather that word might spread through the hills that a cardiologist is doing a paracentesis. I thought to myself he's either a genius or an idiot. Either he would be considered the greatest cardiologist that every lived, or he might start getting 3 am consults from the GI service to do their paracenteses for them.

This story is but a microcosm of what is wrong with our fee for service health care. A heart hospital that doesn't stock paracentesis kits. A specialty that doesn't want to do them, even though ascites is a big part of GI medical training. And a cardiologist, a hard working one at that, who's willing to do it himself because he's too embarassed to ask a general surgeon to do it for him. That's a true internist at heart.

And through all this, I forgot to ask. Where was the hospitalist? I would have been all over that, if I wasn't too busy playing preop for dollars on healthy 34 year old pig farmers.

Would You Take Medical Advice From This Guy?

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What Is The Role Of an Internist?

A healthy 34 year old pig farmer presented as a direct admit for disc removal after injuring his back while playing softball. A healthy guy with no chronic medical conditions. A non smoker a non drinker, the man takes no medications. Has no family history of concerning disease. A hard working functional male who needs his back operated on.

This is about as healthy a human specimen as you can get. So I get called by Happy's nurse coordinator that the surgeon is requesting a consult for "preoperative evaluation".

What I found in the chart was quite telling. A very thorough H&P from the surgeon's office, performed by the surgeon's physician assistant, just three hours earlier.

It had every component of a level 3 H&P

1. Four components of HPI
2. Past medical, family, social histories complete with allergy and medication histories
3. A complete 12 point review of systems.
4. A high level physical exam
5. All components to meet a high complexity decision making process

What was the final plan? Admit to hospital for surgery. Consult hospitalist for pre operative evaluation.

Here's what I don't understand. PA's presumably trained in an acute care setting. They have been exposed to many disease processes. They frequently cover emergency rooms with limited and remote oversight. If PAs are capable of doing that, should they not be able to risk stratisfy a healthy 34 year old for a preoperative opinion on a non vascular surgery?

Is this a risk thing or a laziness thing. I understand the laziness thing. Patients who present to the hospital for semi emergent semi elective surgeries who "couldn't get in to see their PCP". We are asked for our opinion on preoperative "clearance". to produce an H&P by 8 am. I know it's not the patient's fault. The surgeon is often too busy in surgery to meet their obligations as a surgeon. I can even understand the medical evaluation thing. Patients with multiple comorbidities should see an internist for elective stratification of their disease.

But not two hours before their scheduled surgery. And certainly not on the healthy ones.

The risk thing, I don't understand that. Is it ignorance? Is it fear? Is it their lack of faith in the abilities of the PA who trained to know this stuff? In this case, there was already an H&P done. A beautiful level 3 H&P by the surgeon's PA. A note that will probably pay $250 in addition to the bundled fee for the surgery itself.

So why does the patient need a consult from me? I just don't get it. What a waste of my time and your premium dollars. I'll get paid. And I'm sure the private insurance will pay quite well. Why will I get paid? Because I was asked to see the patient. And my documentation supports the request.

And your premiums will go up to pay for my consult. A consult that meets "medical necessity". Why? Because it does. It always does. It just does.

This is a classic example of the presumed 30% wasteful spending in American health care. Do we need an internist to see a healthy 34 year old pig farmer for semi elective nonvascular surgery. And if so, does the public Treasury or your insurance company have an obligation to provide what I think is a medically unnecessary request? The answer is no. But they will. Every time.

Imagine if the surgeon's fee was reduced to pay for such an opinion. How much risk do you suppose the surgeon would be willing to accept if their bundled fee was reduced to pay for an internists opinion on "clearance." How much extra time do you think they would find in the day to screen their healthy patients for a low risk surgical intervention.

I can only suspect that if you provided payment for episodes of care, this kind of waste would go away. The good doctors who practice sound medicine would benefit by reducing the waste and the bad ones would either quit or accept a reduced fee for their inability to cogitate.

It Must Have Been Drive Your Lexus To Work Day At Happy's Hospital

click picture to enlarge

Six for Six.

The Greatest Gift A Physician Can Give His Patient Is The Right To Die With Dignity

I once had a patient. An 87 year old man who lived in his own home. He mowed his own yard. He shopped for his own groceries. He cooked his own meals. He did his own laundry.

Like every functional 87 year I have ever seen in Happy's Hospital, he believed he would live forever. He did everything right in life. He never smoked. He carried a strong work ethic. He remained physically active, even taking in an occasional game of golf. He was the kind of man that drew people towards him. And he was loved. Oh was he loved. So many people. His room was packed. Man was it packed.

Then one day everything changed. It was his neighbor who found him. Bill always got his newspaper at the crack of dawn. But not today. What his neighbor found was a man without words. Barely able to breath. Unable to respond.

The field squad did what all great first responders do. They intubated him. The devastating nature of Bill's disease became apparent fairly quickly. Massive intracranial hemorrhage. Yesterday Bill could do everything. Today he could do nothing.

The neurosurgeon looked at the films. He looked at the patient. There was nothing he could do. Sure, he could offer the family clot evacuation and ventriculostomy. But for what end? Would it keep him alive? Perhaps. Perhaps not. Would Bill survive without surgery? Perhaps. Perhaps not.

Doing surgery may keep him from herniating. It may keep him alive. Or it may not. Nobody can say for sure what the outcome would be if he did something. Or if he did nothing. Nobody knows. What we have is a patient who lived their life well and finished strong. In the end, it's not about how much money you make, how many cars you own, how many vacation homes you bought. It's about people. It's about loving the people around you and trying your best to make the world a better place. It's about leaving your legacy of goodness for others to sunbath in.

The worst thing we could do for Bill was to offer him a therapy that turned a life worth living into a misery worth dying for.

I spent half an hour with Bill's family, explaining to them the grave nature of the situation. The surgeon never offered surgery. I never offered a countering opinion. Was it the right decision? Should the surgeon have offered an intervention that could have saved his life? Did the patient's family have a right to demand the option of surgery? Should the surgeon be willed into doing something he or she feels may or may not provide benefit? Even if the randomized controlled trials (none of which would be powered for 87 year olds) suggested a bias toward survival with surgery, should that data alone will a surgeon into emergency surgery if his medical opinion says otherwise? Is the medical judgment we as physicians bring to the table irrelevant in our practice?

Bill died peacefully with a full house of friends and family. I've been in this situation many times before. Many times before where patients die a miserable death filled with broken ribs, and broken hearts. What struck me with Bill was how peaceful he was. Mixed amongst the beeping telemetry monitors, the beeping IV poles and the beeping ventilators was just peaceful Bill listening to the orchestra of sounds around him.

We as physicians are very capable of taking a peaceful and natural process and turning it into a horrible, painful and emotional roller coaster that will ultimately be filled with nothing but disappointment, heart ache and bankruptcy. We as physicians are very good at avoiding reality ourselves. It's much easier to look a patient in the eye, offer them everything and say, "It's your decision. What do you want to do?"

We as physicians are very good at avoiding end of life decisions. It's easier just to do surgery because we're doing something. And, well, it's just quicker and easier. It's easier to give chemo because we're doing something. And, well, it's just quicker and easier. It's easier to intubate grandma because we're doing something. And, well, it's just quicker and easier.

By doing something, we as physicians are robbing the greatest gift we can give a patient. And that's the right to die with dignity. I will not step down from my belief of letting our elderly die peacefully, when I and everyone around me know the horrors that await them should we decide to offer them everything, when we all know that by offering them everything, we are in fact giving them nothing.

Death is not miserable. A miserable death is.

Happy('s) Gardening

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You Don't Know What You Don't Know

From the Department of Psychology at Cornell comes this 1999 conclusion (via Dr Ves Dimov's Twitter)

People tend to hold overly favorable views of their abilities in many social and intellectual domains. The authors suggest that this overestimation occurs, in part, because people who are unskilled in these domains suffer a dual burden: Not only do these people reach erroneous conclusions and make unfortunate choices, but their incompetence robs them of the metacognitive ability to realize it. Across 4 studies, the authors found that participants scoring in the bottom quartile on tests of humor, grammar, and logic grossly overestimated their test performance and ability. Although their test scores put them in the 12th percentile, they estimated themselves to be in the 62nd. Several analyses linked this miscalibration to deficits in metacognitive skill, or the capacity to distinguish accuracy from error. Paradoxically, improving the skills of participants, and thus increasing their metacognitive competence, helped them recognize the limitations of their abilities.

Put In Simple Term: Education =Ability

Put In simpler terms: You Don't Know What You Don't Know

The less you train, the less you know and the less you really know about what you think you know and the less you know about what you don't know but think you know. In medicine, education is everything. There are no shortcuts to rising above the "incompetence that robs them of the metacognitive ability to realize it."

It couldn't get anymore eloquent than that.

How Should You Take Your Synthroid or Levothyroxine ?

A reader asked the question:

Why is it important to take my levothyroxine at the same time every morning? Perhaps I would be more motivated to meet this requirement if I understood it.

Also, the instructions say not to eat anything for 30 to 60 minutes after taking it. What about fluids? Can I drink water? Diet coke? Milk? What exactly am I trying to avoid?

First of all, I don't think it is necessary to take levothyroxine at the same time every day.  Is it necessary to take it in the morning or evening everyday?   It isn't but doing so will increase the likelihood you will remember to take it every day.  The half life of levothyroxine approaches seven days. Some studies have suggested that taking  once weekly Synthroid or levothyroxine may have some therapeutic benefit for compliance issues.  Say I accidentally took a double dose of my Synthroid.  I've done this before if I took it in the morning and couldn't remember.  Should I worry?  I wouldn't worry about any long term consequences.  I may skip my following day or I may go ahead and take it.  I don't think it will make much clinical difference in the end.

So while I'm not your physician, and nothing I write here is considered medical advice for anyone, I can tell you that I don't believe that the average Joe is harming themselves by varying their synthroid dose through out the day or if they accidentally took an extra dose of Synthroid or levothyroxine.

I myself take levothyroxine at a dose of 137mcg per day (which is about 1.6 mcg/kg, the recommended dose of levothyroxine or Synthroid). On occasion, when Mrs Happy forgets to remind me, I will take a double dose the next day. I will take the pill at night when I normally take it in the morning.

It's important to take it on an empty stomach ( I go with no food or drink for one hour after taking it) so that its absorption is not affected. There may be some absorption issues if you take it with other meds too. You'd have to look that up.

I Once Had A Patient

I once had a patient present with a perforated duodenal ulcer. Nine days after over sew, he had a minor melenotic stool. The surgeon preferred to do nothing, suggesting the blood was likely old and working its way through the small bowel. It sounded like a very plausable explanation and watchful waiting could safely be employed. The gastroenterologist preferred instead to recommend a colonoscopy. To the surprise of everyone, a large right fungating colonic mass was discovered, leading to a hemicolectomy on post op day ten.

I once had a patient, a young healthy functional patient present with substernal chest pain, minimal risk factors for coronary artery disease, a normal looking ECG, negative cardiac enzymes a normal looking echo and a negative cardiac stress test. The patient was the antithesis of underlying cardiac disease. I made a decision to ignore all the negative clinical data and get a cardiology opinion regarding the utility of cardiac cath. To the surprise of everyone was the multivessel disease on catheterization resulting in the recommendation for bypass surgery.

I once had a patient, a young healthy functional patient present with atypical chest pain, minimal cardiac risk factors, a normal ECG, negative cardiac enzymes, a normal looking echo, a negative cardiac stress test, a heart rate of 74 a normal blood pressure and an oxygen saturation of 98% on RA. Despite all the negative data, I ordered a CT angiogram and to my surprise was a massive saddle embolism.

Three patients. Three three complaints. Three conditions. Three surprises. Big surprises. BIG surprises.

Not in a million years would I have thought the patient with the duodenal ulcer would have had a colon cancer too. Not in a million years would I have thought the low probability chest pain would need bypass surgery. Not in a million years would I have thought the no probability chest pain would need anticoagulation for a massive PE.

Not in a million years would I have predicted the science of disease could have been so wrong.

So what am I supposed to do now? Do I walk through my life as a hospitalist, thinking every patient with chest pain needs a heart cath? Do I walk through my life as a hospitalist thinking every patient with atypical chest pain needs a CT angiogram of their chest? Do I walk through my life as a hospitalist thinking every post operative ulcer surgery who bleeds needs a colonoscopy?

I suppose I could. And I suppose I could practice fearing the unexpected. Fearing that a missed diagnosis was some how my fault. Fearing that some how a patient would blame me, or worse, sue me for missing a diagnosis that fell outside the realm of sound clinical practice. I suppose I could treat every patient as that patient I once had. I could recommend cath to everyone with chest pain. I could order a CT on everyone with atypical chest pain. I could recommend a colonoscopy in every post GI surgical bleed.

And I would be failing my duties as a physician.

I know dang well that I will miss a major diagnosis, probably many times in my career. By sheer numbers alone, in a career of 30 years or more, at 2500 encounters or more a year, to expect perfection in 75,000 patient encounters would be irrational.

All I can do is hope I use sound clinical principles, evidence based medicine and a touch of luck to find those patients who fall way outside the normal presentation of common diseases. Every day I hear physicians talk about the patient they once had. Some physicians use the patient they once had as a justification for pretending to practice good medicine justifying every lab, every procedure and every expensive evaluation in the search for another example of a patient they once had.

It should be our goal as physicians to practice good medicine. Our goal is not perfection. Perfection is irrational. It drives irrational standards of care. If we strive for perfection, we will always be disappointed. And our country will be broke. Good medicine will not guarantee against a bad outcome. It will guarantee a reduced probability of a bad outcome.

If we as physicians strive to practice medicine by expanding our list of patients we once had, we will have no money left to treat the patients we currently have.

It's time we stopped treating patients we once had and start treating patients we currently have.

Would You Rather Get Care From A Doctor In the Top Tenth Percentile of Quality Or Top Tenth Percentile Of Income

From the New York Times:

A form of bundled care (salary)

By contrast, Bassett — like the Cleveland Clinic and a small number of other health systems in this country — pays salaries to all of its doctors. No matter how many tests or procedures are performed, they take home the same amount of money. Medical costs at Bassett are lower than those at 90 percent of the hospitals in New York, while the quality of care ranks among the top 10 percent in the nation, surveys show.

Fee for service

But for some, wages are not enough. Dr. J. Turner Stauffer, a gastroenterologist in Thomasville, Ga., left Bassett 10 years ago. He has four children, including two of college age.

“To provide for my family, I felt I needed to be reimbursed on a fee-for-service model,” Dr. Stauffer said. “I make three to four times what I was making there, although I don’t know what my salary at Bassett would be now.”

Dr. Stauffer would not reveal his pay. A recent national survey found that gastroenterologists earned $457,000 on average, with the top 10 percent making $715,600.

So I ask you, would you rather get your care by a doctor who delivers care at the top tenth percentile or the doctor who earns in the top tenth percentile.

Some would argue that the doctors in the fee for service work harder. Perhaps it's time to ask that they stop working so hard. There seems to be an inverse relationship with working harder and providing better care.

Is This Ignorance Or Fear?

I had an interesting conversion the other day with The Happy Cardiologist. In my discussion about the shortage of radioactive tracers for pulmonary embolism scans (V/Q) I was asked, What would I do?

happy cardiologistYesterday 03:03 PM

HH,

Agree, many tests are difficult to interpret in obese patients. Even a BNP can be falsely low. But if the BNP, troponin or RV function were markedly abnormal, then that would add more urgency to the matter due to mortality risk. If all normal, then a more wait and see approach appropriate. Just another tool to assess risk and benefit.

On another note, I was asked to see a 360#, 5'3'' diabetic patient with a history of multiple bilateral PE, for a single episode of atypical chest pain. The CT as read by the radiologist was indeterminant for possible single lobe PE, due to poor contrast timing and patient obesity and movement. The EKG as read by the machine was normal and then overread by a physician as abnormal with ST elevation in the lateral leads (it was normal). I was asked to consider a pulmonary angiogram or cardiac catheterization. The echo was completely normal, with surprisingly good images. Normal RV function. BNP <>

What would you do?

I answered that I wouldn't do anything but refer them for gastric bypass. The Happy Cardiologist concurred. But, the question shouldn't be what would I do if I was the cardiologist. The question should by why is the referring doctor, presumably a family medicine doctor, outpatient internist or hospitalist even asking you to see the patient. There are only two possible reasons:

• Ignorance
• Fear

If the doctor is ignorant, we need to pay them less for costing the health care delivery system more. More referrals cost more money. Bundled care would cost this referring doctor because more referrals means more cost to the health care system. Bundling the care would force them to think long and hard about their duties as a physician. If they are ignorant, they need to go back and train longer. Otherwise, the alternative is to bundle their care and pay them less for their ignorance.

If the family medicine doctor or the outpatient internist or the hospitalist decided to handle this situation on their own, using evidence based medicine and sound clinical judgement, they get no reward. In fact they get higher perceived risk (even though known exists). They not only cost the system less with decreased referrals and presumable fewer unnecessary testing, but they get none of the reward for their great care.

Some folks would argue this places too much incentive on the family medicine, internal medicine and hospitalist docs to not refer care. And that's exactly the point. If you have good doctors doing their jobs for which they were trained, they should be rewarded for their excellence. While those who run volume mills out of a need to financially survive, or out of ignorance should not. Right now, fee for service rewards the doctors who run volume mills either out of ignorance or by pretending to practice great medicine. With bundled care, the doctors doing their job well would be rewarded. All the rest would suffer (those taking advantage of fee for service).

If the happy cardiologist was not referred a patient out of ignorance, the only other alternative is out of fear. Perhaps the referring doctors don't feel like taking all the risk for making a medical decision that leads to a bad outcome. I refuse to play this game. Asking another doctor to give me their opinion will always be out of ignorance on my part, not out of fear. If I wanted to spread the risk, I would be asking for a subspecialist on every single patient I see, for every single new or old medical problem. Playing the risk game is what created irrational standards of care. So many doctors practice out of fear, they have created standards which can't be achieved. It is a horrible way to practice medicine. The solution to fear based medicine is not to do more of it (which is obviously not working) but rather to do less. To establish lower community standards. Standards based on doctors, not lawyers.

This consult request by the Happy Cardiologist is a microcosm of what's wrong with our health care delivery. The great doctors who do nothing shoulder all the risk from irrational standards where many cardiologists would just cath this patient and collect their $500 for passing go. Those who don't, and instead practice sound clinical cognitive based medicine, shoulder all the risk and none of the financial benefit.

And because of that, we get exactly what we pay for. Expensive, irrational health care that no one can afford.

Can We Manufacture As Much Chemo As We Need?

A reader is way off the mark in understanding that medical care is not an unlimited resource. Everything costs money. Some may believe health care is a right, but choose to put no economic limitations on those rights, because it's well, a right. And you can't place a limitation on a right. Right?

I argued in this post that we should not be giving chemo to a 92 year old with metastatic breast cancer, and at the same time almost always deny a liver transplant to patients over the age of 70. The reader suggests that liver transplants are in short supply. As for the chemo? Well, read on...

FInnToday 11:35 AM

Your argument compares apples to oranges. We don't offer liver transplants to those 70+ but do offer chemo to those 90+ because the latter, unlike the former, does not preclude our ability to do the same for someone else. We have a very limited number of organs available for transplantation but can manufacture as much chemo as we need. Transplantation involves major surgery; port implantation is minor surgery. Transplant patients must take immune-suppressing drugs and face heightened risk of infection for the rest of their lives, but we have no way of knowing in advance whether the chemo patient will suffer mild or severe immune suppression (which can be treated) or other side effects. And you can claim that the 92-year-old isn't going to respond to chemo the same way as a 57-year-old but this is a guess based on assumption, not science; as you point out elsewhere (but ignore when it doesn't support your argument), the studies have not been done.

I"m sorry to burst your bubble Flnn. The reason our country is 85 trillion dollars in the hole in unfunded mandates is because people like you believe we can just "manufacture as much chemo as we need"

Let me ask you one question. If the solution to ending poverty as we know it was simply "to print as much money as we need.", why don't we just give all the poor people a million dollars in cash. Wouldn't that solve the poor problem as you see it with the chemo issue?

Of course, the reason we don't do that (at least not to that degree, yet), is that everything costs money. And someone is going to pay for it. Whether it's you or your neighbor, promising as much chemo as we need costs money. And we simply don't have the money to promise chemo to everyone, or to print a million dollars for every poor person in this country.

Your entitlement mentality is part of the problem. Perhaps the only thing you have a right to is to thank the Lord you make it to 92 years old in one piece.

The Difference Between Free Speech As A Right and Health Care As A Right

I've never thought of it like this before, but it's a good point. If the government were to decide which parts of health care were rights and which weren't what would that look like if a government body decided which parts of free speech were rights and which weren't.

Mr. Jones, you can say X and Y, but not Z. Ms. Smith, you can freely assemble with Aleutians, Freemasons, and carpenters, but you may not meet in public with anyone from Cleveland or of Albanian descent. Mrs. Wilson, you may pray to Vishnu and Crom, but never to Allah or Buddha, and when you do pray, you cannot do so for longer than 20 minutes at a time, unless it is one of several designated holidays. Please see Extended Prayer Form 10–22B.

That's a great point. If the government is going to decide which parts of health care are a right and which aren't, based on cost and political whims, than our rights become nothing more than pawns of the economic and political realities of the day.

Perhaps you want the right to free speech to be applied based on who's in charge of the Senate Finance Committee, or which lawyer got elected to the Board of Comparative Effective Speech.

via Instapundit

Will ObamaCare Euthanize Granny?

From the Washington Examiner (via Instapundit) comes this tidbit. An email circulating around the internet claiming ObamaCare will knock off granny. The email says:

On Page 425 of Obama's health care bill, the Federal Government will require EVERYONE who is on Social Security to undergo a counseling session every 5 years with the objective being that they will explain to them just how to end their own life earlier."

This optional benefit allows for one end of life counseling session every five years. I would say that is a great idea. What I know from practicing hospitalist medicine for six years is the vast difference in preparedness for their mortality between patients and families. Some patients, even frail 90 year olds believe they will live for ever and refuse to allow natural death, instead choosing heroic measures over peace and comfort. Some families wish the same despite patient wishes. And some families and patients understand the limitations of our ability to prolong quality on this earth.

Too often I have had to take care of frail, chronically ill, pained old men and women who don't understand what we physicians can offer and get frustrated at the lack of improvement in their lives.

As I tell the families of mothers and fathers, grandmothers and grandfathers, your loved one is dying. I tell them that something in this world will take all of us. Whether it's a massive heart attack, overwhelming infection, sepsis, pneumonia, bleeding out, stroke. What ever it is, something will take their life. I can offer them my experience with treating debilitated and frail elderly in the ICU and how doing so often delays death by a few days to a few weeks. How doing so will leave patients incapacitated, potentially for ever, with all loss of dignity.

Few people want to live like that. Few understand the limitations of our ICUs. Most of what we do is nothing. We are the best waiters in the world. We have no where to go. We can wait and wait and wait. We throw antibiotics and blood pressure medications at you. We have complicated fancy looking machines that don't fix anything. Ventilators that don't fix the lungs. Kidney dialysis machines that don't fix the kidneys. Everything we do in ICU care is designed to support the body as it makes its own recovery. Us docs are there just to monitor the machines and the medications while the body heals itself. We can't make your kidney grow a new lining. We can't make your blood vessels regain their own pressure. We are there to wait for your body to heal itself.

At some point, at some age, after a burden of disease consumes the patient, the body is simply not able to recover. When you enter the picture of disease with diabetes, morbid obesity, high blood pressure, smoking ravished lungs and blood vessels, you immediately set yourself up for failure. Both doctors and patients often fight to the very last second trying to save granny. When in fact, we did nothing but cause pain and prolong what could have been a peaceful and natural death.

I think this counseling should be available every year. And it should be available for all immediate family of the Medicare beneficiary. Often times, when the elderly can't speak for themselves, we are left to the whims of the daughter who comes by once a year, the son who flies a thousand miles to be at dad's last breath, forcing us to do everything until he gets there. These folks often hinder our ability to provide for a natural death. I'm all for any benefit that brings managed expectations to end of life care.

The Lie Clock

Joke of the day. You'll laugh your arse off.

A man died and went to heaven. As he stood in front of St. Peter at thePearly Gates, he saw a huge wall of clocks behind him.

He asked, 'What are all those clocks?'

St. Peter answered, 'Those are Lie-Clocks. Everyone on Earth has a Lie-Clock.

Every time you lie the hands on your clock will move.'

'Oh,' said the man, 'whose clock is that?'

'That's Mother Teresa's. The hands have never moved, indicating that she never told a lie.'

'Incredible,' said the man. 'And whose clock is that one?'

St. Peter responded, 'That's Abraham Lincoln's clock. The handshave moved twice, telling us that Abe told only two lies in his entire life.'

'Where's Barack Obama's clock?' asked the man.

'Obama's clock is in Jesus' office. He's using it as a ceiling fan.

source: granny's email

Does Obama Owe Physicians An Apology?

EP cardiologist Dr Wes Thinks So. And he points to Obama's remarks the other night:

We wanted to make sure that doctors are making decisions based on evidence, based on what works. That's not how it's happening right now. Doctors are forced to make decisions based on a fee payment schedule that's out there. So they're looking... if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, "I'd make a lot more money if I took this kids tonsils out." Now that might be the right thing to do, but I'd rather have that doctor making those decisions based on whether you need your kids tonsils out or whether it might make more sense to change, uh, maybe they have allergies or something else that would make a difference. So part of what we want to do is free doctors, patients, hospitals to make decisions based on what's best for patient care.

In my six short illustrious years as a hospitalist, practicing medicine with my eyes and ears wide open, I have come to the absolute conclusion that

1. Some doctors practice great medicine for the right reasons.
2. Some doctors practice terrible medicine because they are terrible doctors.
3. Some doctors want to get filthy rich pretending to practice great medicine.

In all situations no one is accountable for anything. Would you go to work for a company that paid you 1/2 what they promised, charged you double the going rate for your parking pass and made a product nobody liked and couldn't afford? That's our health care finance system.

The only people making a financial windfall in the current finance scam known as fee for service RVU economics are the folks pretending to practice great medicine. The good doctors go unrewarded. The bad doctors go unpunished. And the doctors pretending to practice great medicine end up with the financial windfall.

Pretend medicine is costing us billions of dollars a year.

If you want those providing medical care in this country to be held accountable, it's time to start paying the good doctors more, to pay the bad doctors less and to make the pretend doctors quit or retire as their financial windfall gets destroyed.

In his remarks above, Obama was talking about doctor #3. I have met these doctors. These doctors are not few and far between. They are everywhere. And they are killing the good name of Doctor #1's everywhere. Obama owes Dr's #1 an apology. That's it.

We need to protect the Treasury from the rest of them. And that can only happen in a bundled care model of financing. I'm sure of it.

Many other bloggers found it necessary to leave their two cents worth

ED doc at Moving Meat

Hospitalist at Notes from Dr RW

Family Medicine doc at Musings of a Dinosaur

Dr Parks over at Buckeye Surgeon

Few of these doctors choose to hold their colleagues accountable for their actions. I'm saying we have to. To protect doctors #1 and keep them from leaving, we have to flush out doctors #2 and #3. We owe it to ourselves and our profession to stand up for what's right and to acknowledge the faults in our current fee for service. We owe it to our current patients and our future generations to protect the Treasury from the unsustainable health care inflation, driven by over treatment and unnecessary care.

If we can not acknowledge faults within our own profession and work towards a frame work that works most of the time, we have no business being in the business of health care. I acknowledge, as did Obama, that we get what we pay for: costly, well paying, expensive, volume driven, procedure driven health care.

We get this because that's what we pay for. The goal is to change the payment model so we only pay for the care we want. That can't be done in third party fee for service because you cannot hold anyone accountable to cost in this model. That I am sure of.

Should 92 Year Olds Get Chemotherapy for Metastatic Breast Cancer?

Dr Parks at Buckeye Surgeon discusses his recent encounter with a functional 92 year old with metastatic breast cancer (lung and liver) who made a decision to proceed with chemotherapy.

Of course, she didn't look ninety. But she wanted a little more time to see two of her grandchildren get married (assuming they are even in a relationship).

So I have to ask the question. Does this 92 year old have the right to consume the resources used to treat an incurable, fatal and futile disease if it means we wont have the money required to treat another disease that is neither incurable, neither fatal and neither futile?

What if she was a functional 100 year old? Should she be offered treatment?

How about a functional 110 year old? Should she be offered treatment?

When the Medicare National Bank (MNB) was established in the 1960's nobody could have predicted that 92 year olds would be getting chemotherapy and surgical ports for metastatic breast cancer. Medicare was not set up to provide for that care. The MNB was set up to keep people from dying, not to keep them from dying.

Exactly what rational system of rationing are we using here? Is it rational not to have one at all?

Mrs Happy's great grandmother found a hard protruding bump in her abdomen several years ago. She was 90 years old. She was told it was probably a hernia (as did I think so). She was a vibrant functional living at home 90 year old. Two months later she presented to the hospital with shortness of breath and a bloody pleural effusions. Confirmed undifferentiated carcinoma. A month after that, the day after Christmas, she was dead.

She didn't get chemo. She went home, to enjoy the last remaining months of her life around friends and family. She died peacefully at her home, under hospice care.

Could she have undergone a biopsy, surgery, chemo and port? Of course. She could have had it all.She could have said she was prepared for it all: Chemo, infections, immunosuppression, blood clots, pneumonias, sepsis, fevers, chills, sweats, bowel obstructions, vomiting, nausea, pain, delirium, anorexia, severe weight loss. She could have been prepared for it all. She could have done all that.

Why? Because she was a vibrant, functional living at home 90 year old with great grand children who hadn't yet been married.

But she didn't. Because doing so would mean giving up the last remaining months of her life in strange places with strange people, strange noises, strange smells, and loosing all dignity as the struggle to survive consumes your every moment.

I saw great grandma Sylvia up until the day before she died. She never thought she was going to die. That kept her alive until Christmas, which I think is all she really wanted in the first place.

Being 92 and functional is, in my opinion, not a good enough reason to abuse patients in their last few months of life, while we choose to ignore the economic realities all around us.

Call me a jerk. Call me ignorant. Call me cold hearted. The longer we pretend that treating metastatic breast cancer in 92 year olds with chemo and a port is quality medicine, the less relevant we become as a profession.  Instead we should all be dancing for breast cancer.

One Clinical Scenario: How I Handled The Nation Wide Nuclear Isotope Shortage

I learned from my radiologist a few weeks ago that "some nuclear reactor in Canada" that makes "most of the nuclear medicine" tracers went off line, causing a nation wide shortage in compounds necessary to do common medical nuclear imaging. Those imaging studies include something called the ventilation/perfusion(V/Q) scan used to look for pulmonary emboli. This test looks for mismatches in the lung between ventilation (breathing) and perfusion (blood flow). And can be highly sensitive for pulmonary emboli in patients with normal underlying lung tissue.

Now I learned the rest of the story from the WSJ Health Blog. And it's not pretty. In fact, it sounds like this shortage is going to get worse. A nuclear reactor in the Netherlands went off line for maintenance.

This shortage has personally affected my practice. Here is a clinical scenario I was just presented with at Happy's Hospital:

Just the other day I had a post op day 5 spine patient on 4 liters of oxygen, a clear chest xray and no indication of parenchymal pathology. I couldn't do a CT angiogram (CKD IV) to look for pulmonary emboli. I couldn't do the V/Q scan due to the nationwide shortage. We have no tracers available to run them. I ordered venous dopplers. They were normal.

Now I'm stuck. Unexplained post operative hypoxemia in a surgical spine patient with negative leg dopplers. Could this patient have had a DVT that broke loose? I see it all the time. Pulmonary emboli with negative leg dopplers. I wasn't going to empirically treat a spine patient with full dose anticoagulation without compelling evidence of a pulmonary embolism. That could potentially paralyze them for life.

So I made the medical judgement to just wait. And wait. And wait. And HOPE that they didn't die of a pulmonary embolism. He didn't. But what if he did? What if this guy really had a clot? I found myself in the midst of an internal conflict.

Would I be negligent for not making the diagnosis because I couldn't test for it? Then I found myself disturbed at even having to think about the legal implications of my medical actions in this clinical scenario. In fact, I found myself pissed off that I even had to consider the legal implications of my actions in this clinical scenario. Why should I have to worry about being sued for managing a condition that may end with a bad outcome? Why would I be blamed? How could I possible be considered negligent for a missed diagnosis in this clinical scenario?

I could have punted the duties of management and spread the risk down hill and asked for a pulmonary consult (which would be ridiculous). I could have punted and asked for a hematology consult (which is even more laughable in this clinical scenario). But I didn't. I knew their opinions on this matter would be of limited value, just as mine would be.

I found trying to understand what the standard of care would be in this situation. I came to the conclusion that there isn't one. In so many situations I practice medicine, there is no standard to guide me, just education and sound clinical practice experience.

There is no standard for diagnosing a pulmonary embolism in a post operative patient where radiographic imaging was not available. It's not like I could send my post operative patient to another hospital. This is a nationwide shortage. Besides, no surgeon would accept a POD #5 patient from another hospital.

I found myself wondering how doctors in the jungles of central Africa practice without all this expensive technology. I found myself wondering how they make the diagnosis of pulmonary embolism in a post operative patient. I found myself wondering what their standard of care must be like.

There is no way to diagnose a PE short of seeing the clot or being lucky. You can develop pretest probabilities based on clinical findings, but you can't make the diagnosis definitively without seeing evidence of clot in the lungs. And you can't see a clot in the lung with out expensive imaging tests. And you can't do the imaging tests if you don't have the materials to do them.

His oxygen levels eventually improved after a few days of doing nothing. And a pulmonary embolism was not likely the cause. But it's scary to think that a major part of the medical infrastructure of this country, a country that spends more money on health care than any other country in the world, can't produce domestic nuclear tracers for medical purposes. That we are at the whim of Canada and the Netherlands to diagnose pulmonary emboli.

I have just one question. Why?

Obama Was Right About One Thing

Cost is the enemy here. via the WSJ blog

"If we do not control these costs, we will not be able to control our deficit. If we do not reform health care, your premiums and out-of-pocket costs will continue to skyrocket.

…if somebody told you that there is a plan out there that is guaranteed to double your health care costs over the next 10 years, that’s guaranteed to result in more Americans losing their health care, and that is by far the biggest contributor to our federal deficit, I think most people would be opposed to that.

Well, that’s status quo. That’s what we have right now."

Proponents and supporters can argue forever about whether this is the fault of the free market or the fault of too much or too little government. I happen to believe that what we have today is nothing more than an expected result of the government regulations put in place. No matter how you try and structure regulation, capitalism will exploit it.

Every insurance I am involved with has a beginning and an end. If your house burns down, you get a defined compensation. If your spouse dies, their life insurance pays a defined compensation. If drive your car into a garbage can and dent the hood, your insurance pays a a beginning and an end.

With health care insurance, we haven't defined an end point. With fee for service, the costs are unlimited, and therefore our health care inflation is unlimited.

With bundled care, the costs are limited, and there fore our health care inflation is limited as well.

Some folks believe that you can't estimate how much it will cost to take care of a patient with diabetes with complications, coronary disease and six other chronic medical diseases. I think we can. And I think we can do it much cheaper than we are doing it today.

The current model is not sustainable. In any third party model, whether it is the government through taxes, or private insurance through premiums, no one is accountable to cost. FREE=MORE makes providers do more. FREE=MORE makes patients do more. I have come to the conclusion you can't have both fee for service and third party insurance AND not double our expenses in the next 10 years. I personally do not want to spend $25,000 on myself and Mrs Happy's health insurance in ten years.

Obama is right. This is exactly where we are heading. Remember that $25,000 in health care insurance is $25,000 less in take home pay being withheld by your employer. As long as someone else is paying the bills, FREE=MORE will prevail and we are all screwed.

Either abandon health insurance all together, or abandon fee for service. We can't have both and survive.

Would You Stand On Short Flights If It Meant Cheaper Flights?

Irish based Ryanair is considering it. 120,000 passengers were polled on their website. Two-thirds would do it if the flight was free. Just over 40% would do it if the price was half.

Would you do it? And what's your threshold.

Who Got Those Trillions Of Dollars From The Federal Reserve?

Nobody knows, because the people (government) watching the people (government) aren't paying attention. This is an outrage. What happened to accountability in this country? (video below)

via The Daily Bail

Taco Bell Dog Dead At 15

She died of a stroke. I don't think she smoked though.

RIP Gidget.

My Smoking Lecture For All Patients

So I saw a 19 year old three weeks after delivering her baby. During my evaluation she admitted to smoking her entire pregnancy. She also continued to smoke during breast feeding. Not only does this toxic residue stick to everything around the mother (including the baby) but the baby is certainly at risk for consuming any one of the 4000 + toxic compounds in cigarette smoke that is absorbed into the mother's blood stream with every puff. So she got Happy's smoking lecture.

I have a very routine cigarette lecture. I have been told on numerous occasions by many patients, who have been lectured a thousand times before, that my lecture is the best one they have ever heard. I show them why it's never too late to quit. I show them what they are in for if they don't.

I draw pictures of normal lung tissue as a function of time, in smokers, nonsmokers and prior smokers.

I explain very clearly why smoking is a disease of blood vessels far more than it is of the lung. I explain all the side effects they will get if they keep smoking. Side effects most people never knew about.

• Stroke
• Dementia
• Blindness
• Heart attacks
• Heart failure
• Kidney failure and dialysis
• Leg amputations
• Cancer

I tell all my smokers to look in the room. For every smoker in the room, including friends and family, every other one will die an early death from smoking. And every one of them will have a disabling illness for which they will struggle with for years.

I tell all my smokers with dogs and cats that they are placing their loved animals at a big risk of getting cancer and dying a miserable death. This factor alone is a powerful motivator for many to quit.

I tell every one of them with children that their second hand smoke is a toxic cesspool of asthma, allergy and cancer for their kids. If they smoke in the house or car, or any enclosed area where their kids reside, I tell them they are showing a selfish disregard for their children's welfare.

I tell every one of them that they should avoid near contact with any of their children.

I tell them at just one pack per day, at only $5 per pack, they are burning almost $2,000 a year. I tell the 25 year olds that saving the money from just one pack per day and investing it at 5% would generate 500K by age 65. At age 35, you'd have an extra $250,000 to enjoy in retirement.

I tell all smoking young adults of my patients that if they do not quit now, they will not be allowed to get needed health care services that are deemed to be lifestyle related illnesses. Our government will ration lifestyle disease at the rate of bankruptcy we are heading for. That they have to do everything in their power to stay healthy today to prevent a future catastrophic illness and be left in the dark.

This is my smoking lecture. It takes time, something that is not compensated under RVU economics. Most folks, pressed for time will not take the time to practice good medicine. To spend the time necessary to make a difference. This is what volume generated fee for service buys you.

This is also why I think bundled care, when paid appropriately can generate profit for physicians, who prevent complications, prevent unnecessary testing, and use sound clinical practices to improve their patient's bottom line and their own. If I could prevent my patient from experiencing an expected smoking related complication by taking the time to counsel them, I should benefit in the cost savings of that counseling.

Right now, I get nothing to counsel and I get no profit in the savings. Some folks might mistakenly believe that my job is to counsel smokers to quit, whether I am paid for it or not. That I have a moral obligation to provide uncompensated care as a part of my professional obligation. To that I say, the day you wake up and agree to go to work for free day in and day out is the day you have a say in what my duty is as a physician. You don't work for free. Neither do I. When I do it, I do it out of my own free will. That has nothing to do with your sense of my moral obligation to provide it on your terms. Some days I may not feel generous enough to provide free tobacco counseling. Other days I may. As long as my time commitment is uncompensated, you have no say in my duties as a physician. My decision to counsel or not to counsel is entirely based on my time schedule and my generosity.

Now tell me I will be paid to provide smoking cessation counseling and I will gladly entertain my patients with marker in hand. Tell me I will be rewarded with gain sharing on the down hill savings and I will gladly bring a slide projector into every smokers room.

In the case of my new young mother, my lecture brought her to tears. It wasn't the stress of the delivery. It wasn't the stress of being a new mom. It was the thought of her smoking causing her baby harm. How do I know that? Because she told me.

To that I say good. Selfish disregard for your child's safety should bring you to tears. I hold no sympathy for those who consider themselves fully informed and educated and choose to harm themselves or their children by their own actions, nicotine addict or not. What we need in this world are more people breaking down in tears.

After five patients and five strokes (paid for by my increased premiums and government taxes) I have no sympathy for the plight of selfishness smokers.

Addendum:  I'm going to have to tell all my patients that their Apple computer warranty may also void if they smoke.

Five Patients, Five Strokes

All young. All smokers. Do you still feel like lighting up?

Two Of The Most Common Complaints For Physicians

1. It's too busy
2. It's too slow

Right now, it's too slow, but it makes up for the really busy times.

This Is The Best Way To Put Defense Lawyers Out Of Business

The experience at one Michigan hospital is profound:

According to Boothman, malpractice claims against his health system fell from 121 in 2001 to 61 in 2006, while the backlog of open claims went from 262 in 2001 to 106 in 2006 and 83 in 2007. Between 2001 and 2007, the average time to process a claim fell from about 20 months to about eight months, costs per claim were halved and insurance reserves dropped by two-thirds.

Why?

Patients want the truth. That's it. Many suits could be avoided if honest communication occurred at the bed side. Defensive medicine is present because us physicians have created an irrational standard of care. Suing your doctor for not upholding an irrational standard is like suing God because he couldn't part the Red Sea again. If we continue to practice irrational defensive medicine, we have no one to blame but ourselves for getting sued when we fail to meet that irrational standard. We owe our profession a duty to stop practicing out of fear and start practicing out of sound medical principles.

Besides, getting sued is much more about lack of communication than it is lack of medical skills. At some point the profession will have to own up to that point.

Prometheus Is Upon Us

Over at Are You A Doctor? I am referred to a bundling system which very well may change the way the business of health care is done in this country.

Prometheus as it's known.

This is the guiding principle of a pilot payment model called Prometheus, which, by January 2010, will be used to calculate insurance coverage for 80,000 workers in Rockford, Ill., and has already caught the eye of the White House. Why? Because it turns the current insurance reimbursement system on its ear.

I am a strong believer in the bundled payment model. It is a third party version of concierge care, which I think is an excellent way to practice medicine. Bundled care is not capitation in the classic insurance sense. It forces all parties involved to provide cost effective care in the most efficient way possible. It forces suppliers to cut their prices in cut throat competition. It squeezes unhealthy and bloated expenses from the current delivery system. It gets rid of the entire bloated fee for service billing and collection system. The article above discusses heart failure in a 60 year old slightly overweight gentleman with GERD and CAD. The algorithm has determined that this patient's yearly expenses should be $20,750. If the patient costs less to manage, the extra savings generate profit.

For bundled care to succeed, it must carry profit potential. Profit will always drive efficiency, and that's what this country needs. Profit in fee for service generates health care inflation. Profit in bundled care will generate the right care.

I believe, when done correctly, bundled payments lead to the most cost effective and efficient care possible. When given the the choice between fee for service vs bundled care, bundled care will always lead to less health care inflation. We have to accept that health care costs money. There is a moving continuum between doing too much and doing too little, between paying too much and paying too little. I believe that when priced appropriately, bundling provides the perfect balance. The key to success comes not in the failure of bundled systems to align all the forces (which it always will), but rather that the algorithms used to determine the bundled price adequately accounts for expense and profit potential.

Remember, if physicians have are unable to generate profit in the payment model presented them, they will walk away, leading to LOSE-LOSE for everyone. Bundling works when payment structure is modeled appropriately. If you find the right price, patients, doctors and government all win.

Why? Because the incentive will be to do less unnecessary care, not more. Many folks worry that the driving motivation to do less may mean that patients get less adequate care. In fact, if you think about this rationally, doing less care that may make a patient worse would increase the costs incurred by the physician by increasing complications. The physician has every incentive to provide the right care, even if it costs them money, to prevent future complications. It is the perfect way to align the forces of all parties involved.

And it will work in a WIN-WIN-WIN if paid for appropriately.

Physicians are also given enormous freedoms to create system processes that increase their productivity, reduce their overhead and further drive efficiencies of scale both within their office as well as within hospital systems. When given the freedom to innovate, I would not underestimate a physicians internal drive to maximize their income through greater efficiencies. Efficiencies that can only be created when you remove the archaic and destructive fee for service model.

Many current physician visits can be managed by nurses(or even a nurse tech, med aid) by phone, by email, by Twitter, or even a nurse office visit. Allowing physicians to concentrate their time on more complicated levels of care that their training allows them the latitude to dissect. I would not underestimate, by any means the billions upon billions of dollars of savings that could be generated, monthly, from increased physician productivity in the setting of increased access to care in a payment model that lets physicians decide what works best for them and their patients.

If we allowed physicians the creativity to induce efficiency in their practice, you would be surprised at how much greater productivity we could achieve per physician in this country. I know for a fact that the way I am forced to practice medicine would never be acceptable to any corporation in this country, corporations that find themselves accountable to their shareholders.

I am economically accountable to no one. The physician pen, it's been said, is the most expensive part of health care. And that statement holds true no matter where you go in this country.

Being economically accountable to no one is a terrible way to do business. But it's the way we are currently forced to practice. There are no winners in this current payment model. Except those that take advantage of it.

There are many different ways to bundle care. You can bundle care by disease. You can bundle care by doctor. You can bundle care across doctor and hospital. You can bundle care by regional districts, counties, cities and states.

Does it matter? Yes. The more aspects of care you can bundle, the greater the efficiencies. Patient care does not happen in a bubble. Whether you are in the ED, the primary MDs office, the subspecialist office, the radiology suite, the lab, the nursing home or the hospital, the more entities you can involve in the bundled model, the greater the cooperation, the greater the efficiencies and the greater the cost savings.

For example, there is little cooperation between hospitals, each looking to increase their market share in a community. If you can imagine one bundled payment for all hospitals within a county, district or locality, you would suddenly find both hospitals working together to increase efficiencies of scale, if not for any other reason but to maximize their own profits by driving down their operating expenses.

The larger the bundling, the greater the savings. I personally believe localities , (cities, counties) that bundle care between hospital, doctors, nursing homes, labs, radiology suites etc have the incredible opportunity to provide the right access without market saturation and achieve cost efficiencies that force suppliers to reduce their costs of everything medical.

Cities have the unique opportunity to drive innovation outside medical care by increasing access to trails systems, parks, community gardens, and other healthy lifestyle initiatives, that could be paid for with savings generated from decreased health care costs (both direct and indirect), increased productivity from reduced illness and greater tax revenue from a healthier more productive society.

Now, the question is are patients and physicians ready for a radical change in the way we do business? I think the answer is yes. I for one would welcome anything that would stop making physician a major part of the problem by being accountable to no one.

A Dog Kisses a Dolphin

How cute is that? via Nick's Crusade

The "Physicians Have A Moral Obligation" Argument Fails Again

The discussion is getting interesting. Michael Jackson's personal physician charged $150,000 a month to be at his side. A doctor responds, one who has clearly fallen victim to the flawed morality arguments.

NameToday 10:27 AM

So 150,000 a month is what this doctor thought he was worth? I agree with you that govt.and some private insurances don't pay justly, but this doctor was obviously greedy. Your argument that he had to do this because of the poorly paying insurance is pretty flimsy.

Doctors in the United States are granted monopolistic licenses--- That is, no one is legally allowed to do what we can. As the only providers of this care, we are morally obligated--- to an extent--- to provide care to the population. This is the population whose tax dollars are put into educating us (those of us who went to public medical schools anyway). Should we be slaves and just treat everyone no matter what? No, of course not. But should we remember that medicine is not just a job for pay, its a vocation that comes with a higher calling to help those who truly need it? Yes. I think you will find that Michael Jackson's doctor, with his clearly money driven practice, has forgotten this.

I might remind this reader that everyone is greedy. Since we live in a performance driven world, a world dominated by money, everyone has a selfish desire to increase their economic potential. That includes you Dr Name. That includes Michael Jackson. That includes Michael Jackson's personal physician. You have no qualifications to determine how much money is enough money for someone to earn.

Everyone has a right in this country to earn what someone is willing to pay them. That means if General Motors is willing to pay a high school graduate $80,000 in wages and benefits to put cars together, a high school graduate has every right to earn $80,000. If someone is willing to pay Brad Pitt thirty million dollars plus royalties to be in a movie, Brad Pitt has every right in this world to collect his thirty million dollars.

If Michael Jackson is willing to pay his personal physician $150,000 a month to be his personal physician, both have every right to agree to that contract. You do not have any right to call him greedy. Greed is defined by your value system, not theirs. And you have no right to judge your value system better than theirs. Some folks may feel a doctor who makes $50,000 a year is greedy based on their value system. Would you agree with that assertion? Would you feel greedy taking home $50,000 a year while the high school grad takes home eighty grand?

That being said, I see serious flaws with the rest of your argument.

• Just about every profession in this country is granted monopolistic licensure. If you want to be a teacher, you have to be licensed in most districts. If you want to be a vet, you have to be licensed. If you want to be a stock broker you must license with state and federal agencies and meet their requirements. If you want to run your own business, you must obtain appropriate licenses demanded by government agencies. If you want to be a lawyer, you must be licensed. If you want to be a full professor, you must be pass credentialing as determined by the academic institution. To single out physicians as a monopoly is ludicrous. Every field has license requirements. Remember, it's the state and federal government who requires licensure, not physicians. I would gladly waive my $75 a year to license with the state, and my $500 to license with the DEA. Just tell me how.
• If you want to say I am morally obligated to provide care because I have a monopoly based on licensure, than I must also assume you feel all teachers, veterinarians, stock brokers, small business men and women, lawyers and professors are morally obligated to provide me their services as well. I wait for the day that my lawyer feels that way.
• To use the argument that as a physician, tax dollars subsidized my care, therefor I am morally obligated to pay back society, is fatally flawed. You have feed from the trough of entitlement. It's fatally flawed on many levels.

1. First, in my career as a physician, I will pay millions of dollars in state and federal taxes. The state may have subsidized my care. I will have paid them back hundreds of times over in my contribution to their tax bill. The state is the real winner, not I in absolute dollar amounts, In fact, the state should be PAYING medical students who stay in their state to practice. The state wins hands down with a return on their investment of tens of thousands of percent.
2. If you believe that physicians have a moral obligation to take care of patients because they received a state tax subsidy, you must also believe that every graduate of a state fund college has a moral obligation to provide their service to the general public. That means every engineer must work for the state. Every lawyer must work for the state, or grant uncompensated service to the general public. Every professor trained at a state university must only teach at state funded colleges. Everybody who ever trained at a state funded college has a moral obligation to provide their service to the general public. This is clearly ludicrous. Everybody who trained at a state funded college would be forced to work for government, out of a moral obligation to pay back their debts (subsidized loans) to society.

• If doctors who trained at state funded colleges have a moral obligation to provide care to the public, what about doctors who trained at private institutions? Are we now basing moral obligations on economics instead of morality? I need say nothing more. This moral argument immediately breaks down. It therefor has nothing to do with morality, and everything to do with economics. You feel physicians owe the public only if they used state tax dollars. That's an economic argument (fatally flawed, see #1) and not a moral argument.
• You call medicine more than just a job. A higher calling to help those in need. One could say the same thing about nurses. One could say the same thing about defense lawyers. One could say the same thing about clergymen and women. One could say the same thing about the Red Cross. One could say the same thing about the local grocery who hands out free vegetables on Sundays between 1-2 pm. One could even say the same thing about your garbageman, your lawn man and your postal worker. Your higher calling, is based on your value system. The federal government gives physicians no special "Higher Calling" tax breaks. It gives them no special protection against civil or criminal acts. God gives them no free pass into the pearly gates. In the world of morality, every one is treated the same. What makes a doctor a good person is no different than what makes the crack addict a good person. You seem to believe physicians have a calling. To that I say everyone has a calling. Physicians are not special by any means. And the expectation of their specialness is based on a lack of understanding morality.
• If Michael Jackson's physician is money driven, to that I say who cares. You should not concern yourself about the moralities others choose to live. His morality may be different than your morality. That does not make yours anymore right than his. By judging him as greedy, you are showing your own moralistic flaws. That doctor has every right to charge what ever he wants, to see one patient or 1000 patients a day, and to create contracts of care with whomever he wants for however much he wants. Now, if he wants to get into contracts of care with third parties which dictate how much money he can make, he has every right to do that as well. That's the beauty of freedom.

Health Care Is A Right, As Long As Someone Else Is Paying For It

This paragraph is classic. It refers to the mandate for individuals to buy their own health insurance in Massachusetts.

Modelers may take into account the experience of Massachusetts, which has taken steps toward universal coverage and has become a laboratory of sorts for observing consumer behavior in the face of new health-care choices. Jon M. Kingsdale, executive director of the state agency administering new health-care plans, said that for those new enrollees buying unsubsidized plans, about 70% chose the cheapest plan available to them. “We were surprised by the extent to which consumers migrated to our lower tiers,” Kingsdale said. Meanwhile, for subsidized plans, new enrollees chose on “breadth [of coverage], and then price.”

FREE=MORE. Of course this makes sense. In other words, if someone else is paying for it, you want the most inclusive and most expensive options available. If you have to pay for it, you choose the cheapest.

What that says to me is that people only believe health care is a right, if someone else is paying for it. But if you you have to pay for it, your only right is for what you can afford.

Here's what should happen. Those that must be subsidized (even if it's just a little) should be offered the cheapest available unsubsidized plan and nothing more. Those getting free or subsidized health care should not get benefits greater than those who must buy their own unsubsidized insurance with their own hard earned money. Call it rationing. I call it fair.

Is It Unethical For Physicians To See Fewer Patients?

A reader brought up this assertion regarding Michael Jackson's Personal Physician being paid $150,000 a month to be by his side 24 hours a day.

Brianna Gamma50 minutes ago

I don't blame him for charging that much money. He can charge whatever he wants.

I blame him for the unethical decision to provide care for only one person, who was presumably not 24/7 sick, when his colleagues struggle to meet the pressing needs of patients in a country with a massive doctor shortage.

Private, personal physicians should not exist when we have such a low doctor-patient ratio in this country. He doesn't have to work 80 hours a week and see thousands of patients, but only one is rather unethical on his part.

The commentor suggests that the physician has an obligation to see more patients because of the low "doctor-patient ratio" in this country.

Many people would argue the same about concierge service. Where physicians limit their practice to several hundred patients who pay fees to the doctor to provide unlimited access, quick appointments, home visits, internet visits and what ever else feeds their fancy. Concierge care is only possible by limiting the number of patients a physician must care for. There are only 24 hours in a day. If some patients wish to pay several thousand dollars a year for the right to have access to a physician they feel brings them an exceptional value, both patient and physician have every right to do so.

The unethical part of this debate is not that the physician feels a desire to make a living outside the constraints of third party medicine. But rather, the unethical part of this debate involves the low payment rates offered by your government and your insurance companies for providing a service that is worth more to people willing to pay it.

Physicians have every right to create contracts of care directly with the patient. And they have every right to charge what the market will bear. If that means fewer physicians for every one else, that is a direct result of the poor payment models being offered by third parties, not the unwillingness of physicians to sacrifice their well being to be others slaves.

The public has no right to tell anyone how much they should make. The market does. The government is not the market. As long as physicians accept government insurance or other third party insurances , they are saying the payment is adequate.

Not until physicians leave their status as pawns in the insurance market will any real reform happen in the patient-doctor-insurance relationship.

There is a major reshuffling going on right now within the RVU system. Some specialties are being hit hard. As long as physicians accept the insurance, even with a 10% cut, they are saying that they are OK with the cuts.

It will take physicians walking out to force change. This is what primary care has done for the last two decades. They have walked out, possibly never to return.

If you want to blame a physician for only seeing one patient or for joining a concierge group, perhaps your anger is misguided. You should blame the third parties who decided the physician wasn't worth what they feel they could command.

You must also blame all nurses who retire early to take care of their kids. You must blame all nurses who choose to pursue non clinical work. You must blame all lawyers who pursue fields not related to public service.

No one has a right to claim another's sweat and tears as their own. If you think this physician has an ethical obligation to see more than one patient, you are free to pay him what he thinks he is worth to get his services.

Otherwise you believe in slavery.

Need A Job? Follow The Money

What a surprise. Washington DC

In a world where unemployment is climbing, does it not surprise anyone that those spending your money can create jobs out of thin air?

Do We Need To Induce A Health Care Recession?

click to enlarge

This is a graph of per capita health care expenditures in 2007 from the OECD. Look at this graph and think rationally about what it is saying. Here's what I see it saying.

It shows the United States government spending a per capita of about $3,200. But remember, between Medicare/Medicaid, only 100 million Americans are covered. That means the actual cost per beneficiary is about $10,000, if the per capita universe was everyone getting government health care. All the other countries do. And their cost is around $2,800 per person. One could argue that the $10,000 tag is high because it only involves old, poor, disabled people. And that argument would make sense, until you see the numbers below.

How much would we have to spend per year to cover 300 million Americans at an average of $2,800 per person, as the next 15 socialized European countries are doing?

$2,800 per capita * 300,000,000 Americans= $840 billion dollars.

Our government currently spends 1 trillion dollars to cover 100 million Americans. If we want our government to act like the next 15 socialized European governments, it will have to cut $160 billion dollars from the current cost, AND cover an additional 250 million Americans at NO cost.

Then lets assume that the total out of pocket cost per capita is a very generous $1000, as the graph seems to indicate. That would be an additional 300 billion dollars to pay for health care in this country. That means the total health care universe would be under 1.2 trillion dollars, one trillion dollars less than the 2.2 trillion dollars in 2007.

Now, I ask you, are you ready for your government to cut %15 from their current budget AND promise to insure 200 million more Americans at the same time for no additional cost?

Is it possible?

Yes.

How?

By inducing the largest health care recession in the history of the world. As long as the eye can see, health care has been a recession proof industry. If we want to cut one trillion dollars a year from health care spending, you will have to induce a health care recession by doing the following

• Shut down hospitals by the thousands
• Shut down imaging centers by the tens of thousands
• Reduce the number of physicians, all of them by the tens of thousands
• Reduce hospital staffing for the ones that survive
• Stop offering advanced health care technology
• Stop paying for advanced health care technology
• Ration services based on time
• Ration services based on age
• Ration services based on illness
• Cut payments to everyone by large amounts.
• Deregulate all of health care. It operates on false economies supported by a massively bloated bureaucracy out of necessity.
• Stop paying for lifestyle diseases.

Here's the reality. America is not ready to be like everyone else. Politicians are not ready to induce the greatest recession of all time, a process that would require permanently removing 8% of our GDP overnight. America is not ready to wait for their health care. America is not ready to be told no.

Tell me we can have universal coverage for $840 billion dollars a year and I'll tell you no politicain is willing to sacrifice their political skin to make it happen. The dog and pony show going on in Congress is not health care. It's bribery. The continued bankrupting of our country.

There is only one way to reduce health care spending in this country. And that's to stop spending on it.

Obamacare: "The Curve Is Being Raised" On Health Care Costs

We are in for a world of hurt. Prepare to keep yourself healthy. You had better do everything you can to avoid self induced illness. In the last few weeks I have taken care of four middle aged patients. All with strokes. All smokers.

That means you need to start working out, stop smoking, eat healthy and avoid illness at all costs. Because nobody will be there to save you.

Obamacare is running us right into a financial black hole.

Asked by Senate Budget Committee Chairman Kent Conrad, D-N.D., if the evolving legislation would bend the cost curve, the budget director responded that — as things stand now — "the curve is being raised."

Explained Elmendorf (CBO Director): "In the legislation that has been reported, we do not see the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount. And on the contrary, the legislation significantly expands the federal responsibility for health care costs."

What we are witnessing now is the largest organized bribery in the history of America. The truth is what we have here is a 99 trillion dollar deficit plus 1 trillion. Then it will become 99 plus Change.. Then it will become 99 trillion plus more Change..... The true costs are trillions more than are being acknowledged now. Is this the Change he was talking about?

Michael Jackson's Personal Physician Charged $150,000 a Month

As is being reported:

It was that friendship, not Murray’s specialty in cardiology, that led Jackson to chose Murray to join him on tour, Murray's attorneys say. In May, Murray signed on in an official capacity to beJackson's personal physician — to the tune of $150,000 per month — for the duration of his 50-concert series in London.

Some look at that number and find it offensive. Offensive that a private citizen has the means to pay what they want to have access to the care they wish.

Some look at that number and find it offensive. Offensive that some private citizens don't have the means to afford any health care while others seem to have unlimited access.

Some look at that number and find it offensive that a physician would dare charge such an obscene amount of money to be one person's two million dollar a year personal physician.

Then every forgets that Michael Jackson brings in hundreds of millions of dollars in income. And no one seems to question why one man dare make so much money off the backs of millions of music lovers.

If you think it's unfair for a cardiologist to charge $150,000 a month, don't forget to lay judgement on the man paying him the money to begin with. The beauty of America is that anyone can spend their money however they like.

A Picture Of Government Health Care

click image to enlarge


Notice how far the doctors are from the consumers in this graph. That's government health care for you. Do you think the overhead of Medicare is only 5%? Look what's left out of that equation. What would all those people do without generating work for themselves? For every action, there's three million government workers reacting.

Thanks to a reader for this artistic display of government waste at its finest.

If you're having problems seeing the pic, go here

Marty And Cooper Play Water Sports

In the spirit of summer, in case you missed it, Marty and Cooper playing in the water. You can find other videos by clicking on their picture on the main page

Proposition Disposition

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

Ain't that the truth.

Redistribution vs Economic Growth

We are in for years of stagnant growth, higher deficits and higher inflation. When ever you tax something, anything, you get less of it. From the WSJ (via the TaxProf Blog).

A new study by the Kaufman Foundation finds that small business entrepreneurs have led America out of its last seven post-World War II recessions. They also generate about two of every three new jobs during a recovery. The more the Obama Democrats reveal of their policies, the more it's clear that they prize income redistribution above all else, including job creation and economic growth.

If current requests for tax increase go through, those living in California and New York would see income tax rates of close to 60%. Add on another 5-10% for sales taxes and you're looking at close to 70% tax rates on your income. If you think the government can spend your dollar and get a better value for its money than you can, you have been scammed. You need only look to the 99 trillion dollar hole they have dug for us.

The government could tax you at 100%. And guess what, it still won't be enough. Because it will never be enough. Once the government promises you everything, they will be able to deliver on nothing.

I'm Trying Out A New Comments Format. Let Me Know What You Think

It appears to be much more integrative and dynamic. Some have expressed difficulty with the blogger format for submitting comments. You can post anonymously or sign up with an account (very easy) and post with your normal moniker.

You can also subscribe to my comments, either all of them by RSS feed (now linked to in my middle side bar), or subscribe to comments from individual posts (in the comment section)

Let me know if you have difficulties with this format.

Happy

In The Eyes Of Medicare You Are Nothing More Than a 99223

In case you missed it, this is a repost from 2007. It gives you a sense what the practice of medicine is really like.

In The Eyes Of Medicare, You Are Nothing More Than a 99223

What does that mean? Well. It means everything. And it means nothing. It is the enormous universe of numbered codes (CPT) that every physician must grasp in order to get paid for services provided. In order to remain a viable business, physicians must learn how to code. And they must learn how to code well so they aren't accused of fraud.

The current coding system is ridiculously difficult and vague. So difficult and vague that audits by the Medicare National Bank (MNB) often result in multiple different opinions by the MNB auditors themselves.

You can see much more here in my coding lectures or earn CME at E&M University.

Coding is a system of confusion. I am here to say the coding system is insane. Current coding rules are used by all third parties to determine the economic value of your care. To determine how much your encounter with the patient is worth. Ultimately, the coding system has become the most important aspect of a physician's professional life because coding determines revenue. And revenue determines the viability of the business model. And that ultimately determines how much you take home to feed your family. Dr Kevin blogged about that here.

So let the games begin. The current coding rules are a futile attempt to bring rings of value to medical service. Services which are so vastly different and unique for every patient. I will attempt to walk you through an example of the payment system, and how it relates to relative value units (RVUs) and ultimately how that affects physician payment.

The number of codes are massive. For all imaginable procedures, encounters, surgeries. Any possible health care interaction. Hospitalist medicine is limited in the types of codes we use. So I only have to remember a few.

95% of my billing is based on about twenty CPT codes:

3 Admit codes (99221,99222,99223)
3 follow up codes.(99231,99232,99233)
2 critical care codes (99291, 99292)
5 consult codes (99251-99255)
7 observation codes (99218-99220, 99234-99236, 99217)
2 Discharge codes (99238, 99239)

There are a few others, but these twenty-two codes determine my very financial existence. Medicare says so. Imagine a surgeon, a primary care doc, and a medical subspecialist. Every single interaction has a code. There are codes for codes, modifiers for codes, add on codes, disallowed codes, V codes, M codes. It seems as if the list is endless. And you have to get it right. Every time. Or you don't get paid. Or you are accused of fraud. It is an impossible feat. The process of taking care of patients has turned into a game of documentation. And that has drastically affected the efficiency of the practice of medicine.

Let me walk you through a 99223, the code for the highest level admit for inpatient care. A level three. There is no actual law, as I understand it, on the Medicare books that definitely defines the requirement for these Evaluation and Management (E&M) codes. There are generally accepted guidelines which carriers are expected to follow. 1995 and 1997 guidelines. Even the guidelines from different years are different. And you are allowed to pick and chose from both. More silliness.

You can see much more here in my coding lectures or earn CME at E&M University.

The following is my understanding of what Medicare requires in order to bill a level three admit, CPT code 99223. You must have every one of these components or it's considered fraud, over billing or waste. Pick your verbal poison.

1) History of Present Illness (HPI) : This requires four elements (character, onset, location, duration, what makes it better or worse, associated signs and symptoms) or the status of three chronic medical conditions.

2) Paste Medical History (PMH): This requires a complete history of medical (medical problems, allergies, medications), family (what does your family suffer from), social (do you smoke or shoot up cocaine?) histories.

3) Review of Systems (ROS): A 12 point review of systems which asks you every possible question in the book. Separated by organ system.

4) Complete Physical Exam (PE): With components of all organ systems, the rules of which are highly complex in and of itself.

5) High Complexity Medical Decision Making: This one is great. It is broken down into three areas and you must have 2 of 3 components as follows; Pull out your calculator.

5a) Diagnosis. Four points are required to get to high complexity. Each type of problem is defined by a point value (self limiting, established stable, established worsening, new problems with no work up planned and new problems with work up planned). You must know how many points each problem is worth. Count the number of problems. Add up the point value for each problem and you get your point value for Diagnosis (5a). You must have four points to be considered high complexity.

5b) Data. Four points are required for high complexity. Different data components are worth a different number of points. Data includes such things as reviewing or ordering lab, reviewing xrays or EKGs yourself, discussing things with other health care providers (which I have never been able to define), reviewing radiology or nuclear med studies, and obtaining old records etc. Each different data point documented (remember you have to write all this down too) is given a different point value. You must add up the points to determine your level of complexity. Get four points and you get high complexity for Data (5b).

5c) Concepts. I call this the basket. Predefined and sometimes vague medical processes that are defined as high risk. This includes such things as the need to closely monitor drug therapy for signs of toxicity ( I would include sliding scale insulin in this category), de-escalating care, progression or side effect of treatment, severe exacerbation with threat to life or limb, changes in neurological status, acute renal failure and cardiovascular imaging with identified risk factors. There are too many categories that are defined as a high risk concept. I cannot remember all of them. If you have a concept considered high risk, you get credit for high risk in the concepts category (5c)

Now remember, out of 5a, 5b, and 5c, you must meet high high complexity criteria on two out of three to be considered high risk. Did you remember to bring your calculator to work? And once you've calculated your high complexity category, don't forget to write down all the components required from HPI, PMH, ROS, PE to not be accused of fraud.

Folks, this is what I have to document every time I admit a patient to the hospital in order to get paid and not be accused of fraud. This is what the government (and all other subsequent third party systems) have decided is necessary for me to treat you as a patient. This is what I must consider every time I take care of you.

I always find myself wondering if I wrote down that I personally reviewed that EKG. I wonder if I wrote down that your great great grand mother died of "heart problems". I wonder if I remembered to write down all your pertinent positives on your review of systems and whether I documented the lack of positives in all other systems that were reviewed.

And remember each CPT code is given an RVU value, the value of which is determined by its own three components.

• The work RVU
• The practice expense RVU
• The malpractice expense RVU

Then the MNB multiplies your total RVU (add the three components above) and attached a geographical multiplier (you get more RVUs in NYC than in Montana).

Then, they take that number of RVUs and they multiply it by the Congressional mandated value of the RVU (currently about $35/RVU). That value is currently determined by the political whims of politicians and is controlled by the irrational sustainable growth formula (SGR). That is the formula that is overturned every year because of the irrational economics it employs.

And that's how a physician is paid. This is what determines whether physicians survive in the business of medicine. And whether they have enough money to pay the electric bill, the accountant's fees and the matching contribution to their nurse's 401K.

Oh yeah. I almost forgot, I have to do all this while actually taking care of your medical problems based on sound scientific principles.

This is coding in a nutshell. A 99223. This is what I think about when I'm admitting you through the emergency room. This is E&M medicine. This is Medicare medicine. This is how your government has decided the practice of medicine should be. To get paid, I must document what Medicare says I must in order to care for you, the patient. It doesn't matter what I think is important to write in the chart. What matters is what is required to get paid and not be accused of fraud.

Like I have said before, the medical chart has become nothing more than a giant invoice for third parties to assert a sense of control on their balance sheet. It doesn't matter who that third party is. They are all the same.. I'm telling you, it's nothing more than a really inefficient game of cat and mouse. It is a terribly inefficient and expensive way to practice medicine.

And I might remind you, the exercise above was an example of just one patient on one day. I do this upwards of fifteen times a day. Every day. Day after day. Year after year. Oh yeah, and the rules are different for inpatient followup codes, discharge codes, critical care codes, and observation/admit same day codes. They all have their different requirements. And I have to get it right for every single patient I see. Every day. Over 2500 times a year. With the expectation of 100% accuracy.

Why? You see, in the eyes of Medicare, you are a nothing more than a 99223.
You can see much more here in my coding lectures or earn CME at E&M University.

The Billboard That Bleeds When It Rains

The goal? Slow your driving down in the rain or somebody might get killed. via Gizmodo

(video below)

Don't Pay Your Medical Bills

Comment # 10:

Like William Walden said "don't pay medical bills". There's thousands of doctors just change to a new one every year. That is what I do and don't pay any medical bills. Also I don't care about my credit. I hate to pay after I got a deduction on every paycheck for for that $100 for the famous, corrupted, unfair business of the "HEALTH INSURANCE". Remember "Don't pay medical bills".

I wonder how this guy would feel if his employer also withheld 20% of his paycheck every month because they didn't feel like paying it either.

Tales From the Serenity Now Hospital

Please don't examine him:

"This patient has been to several clinics requesting physicals from female doctors and midlevels. Specifically, he is requesting rectal exams while squatting. Dr. X has confirmed the phone number he gave us is not a working number. Please do not examine him."

Strange indeed

So Who's Fault Is It?

From the Gadget Lab:

It’s hard to decide who are the biggest morons in this story: parents or daughter. 15 year-old Alexa Longueira was walking along Victory Boulevard in Staten Island when she fell into an open manhole.

Why didn’t she see it? You’re ahead of me here. She was too intent on tapping out a text message to notice the gaping gap in the sidewalk and just dropped straight on in. Idiotic, yes, but now Alexa’s parents are trying to blame someone else for their daughter’s stupidity while making a little money into the bargain. They’re suing the city.

How did the girl respond to this tragedy? As one commenter posted, unscathed at the bottom of the sewer pit:

Omg Jill. idk where i am now. it’s 2 dark 2 C. I thk I fell

What do you think? Entitled to a jackpot? Or blatant stupidity.

And You Think Specialsts For Humans Are Getting Ridiculous

You can find a physician who specializes in just about anything these days. Well, apparently it's no different for the dogs either. My partner told me about his Aunt who owns a Boxer. This Boxer is on Sotalol 80 mg bid (human dose) for atrial fibrillation.

This medication is being prescribed by a veterinarian cardiologist, who specializes in Boxers. That's freakin' crazy.

How To Prevent A Costly MRI

Take off the f-ing dressing first.

The Courage To Start

From the July, 2009 Runner's World magazine:

So if you see me at a race, and I look like a 60-year-old guy waddling along, don't worry. I'm fine. I'm better than fine. I'm happy. You see, I remember those words that first appeared here 13 years ago: "The miracle isn't that I finished. The miracle is that I had the courage to start."

That is the essence of exercise. Starting exercise was hard. Now I find quitting even harder.

Which Light Post On The Golden Gate Bridge Is The Most Popular For Suicide?

click picture to enlarge

#69. Bet you didn't know that. Click on the link to see how many people survived the jump.

graphic via SFgate.com

If It's Too Good To Be True, It Probably Is

click image to enlarge

Here's an excerpt from Hot Air

With an average income of about $63,000, families spend $2853 on health care. Interestingly, these strapped, financially burdened people who can’t possibly pay more for their health care do manage to squeeze out $2698 for entertainment, $323 on tobacco and another $457 on alcohol. That’s a total of $3478, or about $290 a month (that doesn't even include $3,200 on cars). Call me crazy, but I say most people can afford to pay for more health care if they really needed to. They’re just calling themselves victims and demanding to be protected from the consequences of their financial choices.

We’re afflicted with a “big screen TV poverty” mentality; we think the failure to achieve a desired lifestyle equates with poverty. Poverty in America isn’t what it used to be; now people classified as poor own homes, one or two cars, have air conditioning, microwaves, cell phones, cable TV and internet. Those people may not be rich, but they’re not what most of us would describe as poor, either.

Here's what I don't get.

We are being told the cost to insure 50 million people over ten years is only one trillion dollars. That's 100 billion dollars a year to insure 50 million people, every year, for the next ten years, assuming a zero health care inflation rate. That's $2,000 per person, per year, every year, for ten years. With zero health care inflation.

Now for a serious question, how can the government promise to only spend $2,000 per person per year for health care , an amount 75% less than the average cost of health care per person currently being spent in this country? Do you believe the entire health care industry has a 300% profit margin?

The Medicare National Bank currently spends around 500 billion dollars a year to cover around 50 million Americans. Our government is telling you it can insure 50 million Americans for 1/5th that cost, or 100 billion dollars a year.

Do the current numbers make sense? The government is telling us they can pay for the health care of 50 million Americans at 100 billion dollars a year for the next 10 years (with zero % inflation), when the same government currently spends 500 billion dollars a year to insure the same number of Americans. And it certainly doesn't carry a zero % rate of inflation.

If you can tell me that the government could fund comprehensive, complete and quality health care every man woman and child in this country for only $2,000 a year, I would say we live in the greatest country on earth. That's cheaper than every Western nation on this earth. I would sign up for that in a heart beat. I would feed from the trough of FREE=MORE.

Even if you use current projections, and discount 30% for this imaginary "waste" factor, what you are looking at is a 350 billion dollar per year price tag to insure 50 million Americans. Assuming zero percent inflation, the cost of government funded health care for 50 million Americans is 3.5 trillion dollars over ten years, not one trillion. Factor in health care inflation and you're looking at another trillion or two by year ten with all the waste cut out.

It's all lies. We are 99 trillion dollars in the hole. The government will never care to tell you the truth, as long as you, the willing co conspirator don't care to hear it. What we have here is a classic case of "If it's to good to be true, it probably is". A government that promises you everything will end up delivering on nothing.

A Psychiatrist Talks About Smoking

A psychiatrist speaks their mind:

When I was growing up, cigarettes were something people bought from vending machines. I've never been a smoker, but I want to say they cost about a dollar? I'm not so sure, and it's not something I pay much attention to. Today, I learned that a carton of cigarettes cost $75! $7.50 a pack, or 38 cents a cigarette. So someone who smokes 2 packs/day, pays about $450 a month.

The funny thing is, I didn't know this because people never complain to me about the cost of cigarettes. They complain about the cost of medicines (this sometimes includes patients with medicaid who have a $1 co-pay for their meds), the cost of health insurance, and the cost of medical treatment. At times, I've suggested that patients with heavy habits cut down by one pack a month (so less than a cigarette a day) to be able to afford their medicines and I've been met with groans.

Of course we should excuse those with mental illness, because that's just what people with mental illness do. They smoke. Right? And it's good for them, right? I mean, take away their cigarettes and they just might get worse. Right?

Actually, most mentally ill patients who smoke want to quit or cut down (just like most non mentally ill people who smoke too). And it's not suicide that kills those with mental illness. It's heart disease. Heart disease that is certainly exacerbated by their heavy smoking.

“The biggest cause of death among people with mental illness is not suicide, it is cardiovascular disease.”

One reader responded with rational truth:

I can definitely say Amen to this post.

As a former smoker, I can tell you that it's not a pleasure to smoke. It leaves your mouth tasting disgusting and your clothes smelling awful.

It's also not a good replacement addiction for eating. I was 240 lbs as a smoker, it wasn't until I stopped smoking and eating and just focused on being healthy that I was able to lose my weight.

How does this relate to hospital based medicine? I find it highly hypocritical that hospitals nation wide are going smoke free, except for their psychiatric wards, where patients are free to wander day in and day smoking to their hearts desire. I would say well over 75% of my inpatient clientele are either actively being treated for depression or are having an acute major depressive episode due to their medical illness.

To deny my depressed inpatients in the midst of life changing medical illness the right to their cigarettes, while allowing those with mental illness, locked up in the psych ward, the right to smoke is an irrational double standard.

If you want to let the mentally ill smoke you might as well let all my depressed inpatients smoke as well.

What Day of The Week Are Suicides Most Common?

Just in case you ever make onto Millionare

Penile Sufficiency: How Hard Is Hard Enough?

Yes folks, somebody paid somebody to answer the question.

In an effort to obtain a more precise definition of erectile sufficiency for vaginal penetration 19 normal men were exposed to an erotic videotape and recordings of penile tumescence were obtained. The subjects were instructed to signal with a push button switch when they had attained an erection they judged sufficient for penetration. They were asked to signal a second time when a full erection had been reached.

from NCBI ROFL via Science Roll

A Rare Look At First Person Shooter Disease

Who knew video games could be so dangerous? (video below)

iPhone Medical and Mobile Apps: Could The iPhone Revolutionize The Hearing Aid Market?

Check this out. Basically, the iPhone and its app functions as a booster for incoming signals. A cheap hearing aid. Instead of spending $3000 or more on a hearing aid, just buy the iPhone for 99 bucks. and use it as your cell phone for the monthly fee.

Have You Ever Played The Religion Card?

Everyone has failed this man, but mostly his family. Go read the entire story and come back. It's a powerful statement on so many levels.

Later that day, we encountered his family, a large group of old Maine Catholics. They seemed to be nice people, but I couldn‘t face them. All I could think was that his family either hated him or had advanced to a state of pure denial. It bothered me, and I couldn’t look at them. It was my first encounter with the dark side of modern medicine, and it was the first time that I ever asked myself: is our help just hurting this man?

I once took care of a patient, who's family was filled with non english speaking devout Catholics. I had no idea whether their religion played into their decision making or not . I can only assume that it did. Their mother was brain dead from a massive stroke. Confirmed by clinical testing. Reconfirmed by brain flow studies. Brain death is clinical death. There is no coming back from that.

On first discussion, their decision was to continue "full support" forever. It would never occur to them to take their mother off the breathing machine. The only thing keeping her heart alive, even though she had already died. Their expectation was to keep her on the ventilator forever and wait for her to wake up.

I don't consider myself to be a religious scholar. I'm not even sure if I did the right thing. But I played the religion card that day. Based on the multiple religious comments that kept presenting themselves during my discussions I realized what this family was looking for was the salvation of their mother's soul.

I told them mother would never come back and talk to them. Ever again. I told them that the respiratory and everything we were doing to her in the intensive care unit was keeping her from finding her salvation. That their decision to continue medical support was preventing eternal peace of their mother's soul. I told them that turning off the machines would allow her to pass on to a place much greater than this.

And less than an hour later, with 30+ family members by her side, the machines were turned off. I'm not Catholic. I don't have any idea what the Catholics preach. I'm not even sure if what I said to the family was religiously correct. But it helped them to do the right thing. And it allowed their mother to leave this earth in one piece. Had I not played the religion card, their brain dead mother would have either died during CPR, or worse, a living dead man.

Have you ever played the religion card?

What Is The Worst Suffering You Can Inflict On Your Family?

When you rescind their clearly stated DNR, you are failing them in their last living moments. I see this all the time. And it's just plain sad.

Your grandfather wanted to die a peaceful, dignified death. Because of you he will linger in the ICU for a few weeks before he ultimately dies of something unpleasant, painful, and expensive. There is almost nothing worse you can do to someone than to remove whatever control they tried to exert over their own inevitable death. You have ruined the last few weeks of his life, and that is an awful thing to do to another human being.

Wonder Why Health Care Is So Expensive?

This cardiologist blames Reflex medicine. I agree. If you live to be 93, your number one goal for the rest of your life should be to avoid doctors and hospitals. They'll end up killing you.

Why Are Some Patients Noncompliant?

A patient (and contributor to Hospitalist With a View) with chronic illness describes why.

It is extremely difficult for patients to balance among multiple specialists. The medical system can be stressful, though necessary. When a patient can't remember a couple of specialists' names despite a decent memory, that patient may be a bit overwhelmed. In my case, today I had an appointment with my rheumatologist, and I have an appointment tomorrow with the dermatologist, an appointment Monday with the neurologist, and now I may have to see a hip specialist and the GI specialist too. I was spoiled by the luxury of having a few months without medical appointments. I have not yet scheduled with the PM&R doctor and wheelchair seating expert so I can get myself sitting up and out in the world more, only because I had been exhausted by appointments and am not thrilled about moving to different equipment.

This is why 5% of the population spends 50% of our health care dollars in the US. Chronic disease is expensive, especially when you are being bounced between a rheumatologist, a gastroenterologist, an orthopaedist, a dermatologist and a neurologist.

Every doc will do something and that something costs money. It also makes organizing your life around something other than your disease almost impossible.

This scenario may soon become a relic of the past. In how many countries now can you get an appointment with five subspecialists in less than a month? The answer will soon be none.

You can find her other musings at FridaWrites)

The Hungry Addict Is Struggling

He's a young guy. He's got evidence of plaque in his coronaries. He's got a wife and kids. And he's struggling to survive.

I went to the cardiologist yesterday. He is a shoot from the hip guy. He reviewed my lipid panel results with me. He was concerned with my HDL being 26. This is the hardest one to budge. Exercise helps. He told me that my ten year risk assessment was pretty ominous looking. Ten years. That is a short trip. That is an hour's drive. "It'll never happen to me."

Hungry. You know better than anyone that it WILL happen to you. What do you think folks? The comments over at his site seem to be split into two camps. One camp wants to kick his ass for not getting it into gear. And the other camp wants to hold his hand and tell him everything will be OK.

I don't know what approach works for you Hungry. I do know I took care of a 37 year old man with a stroke and subsequent hemiparesis. And guess what. He was just like you.

Just like you...

What Is Your Weirdest Patient Request Ever?

I once had a nurse come up to me stating that her patient was "requesting a note saying it's OK to 'be released to my husband'".

What does that mean? Needless to say, I didn't feel comfortalbe writing such a note.

What's the weirdest request you have ever received from a patient?

You The Patient Have Become The Legal Hot Potato In American Medicine

I discussed my thoughts on risk and how all physicians theoretically carry the same risk, not because one field has more bad outcomes than another (which they obviously do) but because all physicians are trained to be experts in their field of training. This expert training should theoretically create no difference in risk between different subspecialties, as long as all physicians practice within their scope of practice.

In a follow up post, I discussed my experience with discharging patients from the emergency department and how this increased my risk exposure not because the science of the discharge is wrong, but rather because the perception of negligence is greater. I discussed the irrational standards of care that have been created out of a legal necessity to avoid litigation at all costs. An irrational standard that creates exponentially infinite costs that are bankrupting this country with little to no benefit to society as a whole. By expecting perfection on an individual basis, an expectation that will never be achieved, we are risking the implosion of affordable care for all. This is physician driven. Driven out of a fear of bad outcomes, which sets irrational standards, which creates negligence when those impossible standards cannot be achieved.

And a reader hit the nail on the head with this comment. I couldn't have said it any better.

as a hospitalist, you are at the bottom of the funnel in the risk cascade.
If you continue to send pts home from the ER, by numbers alone, somebody is going to have a bad outcome and it's all going to fall on you.
If you are willing to accept this, more power to you.


Problem X- undifferentiated, high risk, broad ddx type problem.
ie chest pain, dyspnea,abdominal pain,fever,headache, etc.
PMD busy in office, doesn't want to deal with it.
sends pt to ER for "work-up"
-if something goes awry, "I knew he was sick, so I sent him to the ER".
Then:
ER gets pt, checks a "pan-panel" and multiple imaging studies.
If anything turns up--admit to hospitalist.
If negative-"I don't know what's wrong, better admit."
Hospitalist is now last one standing; if send pt home and adverse outcome= "Doc HH, you mean two physicians thought this pt was too sick to be at home, yet you sent them home?"

Safe move is to always admit--as you say, if adverse outcome in house, doesn't seem as bad.
Now, you have a three way risk pie--and any specialists that were called to consult.

Not great medicine, but the risks are too high to hold it all by yourself

I can't tell you how true this is. This is the basis of establishing irrational standards of care. The last bolded section says it all. You the patient, have become the legal hot potato in your journey through your illness. The rational being, if you put the responsibility of certain aspects of care on someone else, it is that someone else who will ultimately be responsible should a bad outcome occur.

The lawyers want you to believe this doesn't exist. I can tell you categorically, 100%, without a doubt that patients are treated like hot potatoes, in one way or another, with just about every encounter they experience in American medicine.

I have a really hard time playing that game when I have experience and science on my side. At some point, physicians need to be held accountable for the irrational standards they have implemented out of fear and establish standards based on most likely plausible explanations, not the least likely explanation. Until we can do that for our profession, we are a big part of the problem for the financing of this country's health care needs.

Are Dialysis Free Weekends Killing Our Patients?

A very intriguing study (done years ago) was posted over at the Renal Fellow Network. For the non medical people out there, your kidney is like a filter. Your blood goes into the kidney, the kidney does its filter magic and you pee out your excess salts, toxins and water. Now, if your kidneys fail you, you have no way to pee out your salts, toxins and water.

So you get dialysis, which is nothing more than an artificial membrane that pulls your blood out of your body, runs it through an artificial membrane, filters it, and then puts the blood back in you. There are several forms of dialysis, the most common of which is hemodialysis (HD). The one everyone thinks of that pulls your blood out, runs it through the machine, and puts it back in you. The normal schedule for HD is three times a week, either Mon-Wed-Fri or Tues-Thurs-Sat.

I have never seen a patient with their normal HD runs on a Sunday. The study from the above link suggests that the dialysis free weekend is killing our patients.

Those with M-W-F dialysis were more likely to die on Monday (dialysis weekend). Those dialyzed on Tues-Thurs-Sat were more likely to die on Tues (their dialysis weekend). And those patients on peritoneal dialysis (PD) had no day of preference for death (PD is done every day, in the home setting). Intriguing to say the least. One day continuous ambulatory renal dialysis will be standard (much like the insulin pump). That is, if our health care system hasn't imploded by then.

I once had a patient once tell me that the outpatient dialysis unit was "ruining my lifestyle". I asked him how so? "Because I have to keep going in". I asked him what his solution was. After missing an entire week of hemodialysis, he says "I can just come to the hospital."

Yes, of course. That's the perfect solution. Inpatient dialysis is all the rage these days. But just don't come during your dialysis weekend. You may not make it until Tuesday.

Why Do Nurses Write: "no new orders received"?

Doc, over at ramblings of a disorganized mind believes he has the answer:

I always find it funny when the nurses calls me for an issue they are having with the patient and then document "no new orders received." I have read that phrase is a dig at the doctor because you feel something is important and we aren't responding to your worries. Well, my job is to see the overall picture of the patient and if I don't feel the patient needs it, I won't order it to make the nurses feel better.

I don't think writing an order that says "no new orders received" is a dig on doctors. I think it's cover your ass medicine. A nurse is making it clear in the lawyer/billing chart that Dr Smith was notified of the low blood pressure, or the confusion, or the nausea, or the chest pain, or the INR of 2.3 on Coumadin, or the Hgb of 8.1 for the last six days, or the potassium level of 3.3 and they are making dang sure that their perception of a safety issue shifts all responsibility onto the doctor and off of the nurse. It should by OK to state "Dr Smith notified of _____". The extra emphasis of "no new orders received" seems somehow, in the mind of the nurse, to place an exclamation point on the notification. I'm not sure how a jury would quantify the importance of one statement over another. Personally, I don't think it matters.

But I don't blame them for writing it. I'm sure doctors all over this country have used the defense that they were never notified of the nausea or the chest pain or the low blood pressure and a bad outcome ensued. With that said, maybe I should start documenting, "blood pressure medicine given 15 minutes late", or "IV pool was beeping during my evaluation and no one responded". Or "nursing staff won't walk the patient six times a day as requested." "Or patient lying in a pool of stool during my evaluation." Or how about documenting "nursing assessment lacks substance." Or "nursing staff doesn't seem to understand side effects of patient's current treatment." Or "nursing staff failed to notify drop of UOP from 80cc/hour to 40 cc/hour."

Of course I wouldn't write any of that since I find the whole idea of writing "no new orders" nothing more than a perceived form of CYA in this legal driven medicine we practice.

I've had a few cases of critical radiology reports signed out as Dr Happy notified at the time of this dictation, when in fact I was never notified, or I was gone and my partner was notified. The medical chart is nothing more than a giant invoice and legal document. It has long since left this world as a documentation of meaningful medical information. If I spent my entire day worrying about "no new orders" I would never be able to take care of patients who actually needed them.

Tygacil for C Difficile?

Intriguing to say the least. What happens under Obamacare when all else fails and Tygacil may help you but no one will pay for it because it isn't part of the basic health care plan?

The Friday Funny: Medicare Goes Bankrupt

Full time cartoonist, speaker and blogger and part time physician Dr Val sketches the future of the Medicare National Bank.

Really funny stuff doc.

More Dead Patients Are Getting CPR

Free=More

In this national database of Medicare patients >age 65, from 1992 to 2005, the incidence of in-hospital CPR remained steady, but the proportion of hospital deaths preceded by CPR increased from 3.8% to 5.2%. This indicates that CPR is increasingly being performed in patients unlikely to survive, escalating the need for discussions about futility

I could have told you that. Just the other day I took care of a patient with 10 chronic medical illnesses, immobilized in a nursing home.

Full code, despite me spending 15 minutes of uncompensated time describing why the last thing in the world they want to be is full code. I asked him what he knew about CPR. "Just what I see on television" was the response.

We physicians are in for an uphill battle on this one. You won't get physician directed discussions about allowing natural death until somebody pays for it. And pays for it well.

Here's an idea. Perhaps the Medicare National Bank could pay on commission. For every appropriate patient you convince to allow natural death, they send you a $100 check in the mail. And for every 9 patients that sign up, you get your 10th check for free. $100 to save the eventual death of a patient that should be allowed to die naturally while saving $50,000 for that two week stay in the ICU two years from now.

Now that's a market solution to a growing problem. WIN-WIN.

CMS Takes On The RUC

It's getting juicy.

How Can We Justify Performing Upper and Lower Endoscopies On Consecutive Days?

This gastroenterologist answered his own question.

I am not naïve to the fact that most insurers discount heavily for endoscopy procedures performed on the same day. But how do we justify the additional risk, costs, inconvenience, and impact on a patient’s quality of life by not performing needed procedures at the same time?

One more example of how money drives medical decision making. If I was a patient, I would not put up with this. But the lay public doesn't have a clue how often this practice style is employed in the real world.

Should You Send A Bill To A Patient If They Die?

Dr Brayer over at EverythingHealth asks the question. Of course any outstanding bills go to the deceased person's estate. Why are physician's any different?

• Would the funeral home excuse payment for the grave stone of their dead client?
• Would the ambulance company excuse payment if their patient died en route?
• Would your mortgage company excuse their outsanding balance upon your death and give your estate the house?
• Will the US government excuse your estate of your back taxes upon your death?

I think that should answer your question.

Health Care By The Numbers

It's Not Pretty. Governments that promise everything end up delivering on nothing.

10,000: Number of Canadian breast cancer patients to file a class action lawsuit against Quebec's hospitals because, on average, they were forced to wait 60 days to begin post-operative radiation treatments.

The Biggest Winners and the Biggest Losers

Go to page 33661 (found via Clinical Cases and Images) to find out how your medical specialty will do in the upcoming proposed payment changes under the relative value unit (RVU) model. As many of you know from reading here, RVU is the Medicare National Bank's way of setting a value for every possible CPT encounter you have with a patient. It has three components. The physican work component which values the physicians time and education, the practice expense (PE) which is supposed to compensate for the business expenses of the practice and the malpractice component (MP).

So how do the different specialties come out? The biggest winners were optometry (+12%) and ophthalmology (11%). Family medicine comes in at +8%, as does geriatrics. Internal medicine +6%. The Biggest Losers are the diagnostic testing facilities, losing 24%.

If you go to page 33662-33663, you'll notice many specific procedures and E&M codes are taking a big hit. 32% reduction in heart cath? 21% reduction in upper endoscopy with biopsy? Even the hospitalist codes (admission and follow up codes) are taking huge hits of 13%-17%.

Until you read the fine print. These reductions assume that the required 21.5% across the board reduction in the sustainable growth rate formula takes effect in 2010. In other words, only if the monetary value of each RVU is decreased by 21.5% from the current $35. And that will never happen. Not in a million years. So for the individual E&M codes and procedures, I take the actual changes on page 720-721 to be what ever the reported % change is and ADD 21.5%.

That means for hospitalists, you are looking at an 8.5% increase in the high level admission (99233), a 5.5% increase in the high level follow up code (99223), a 6.5% raise in the greater than 30 minute discharge (99239) and a 3.5% increase in the critical care billing codes (99291,99292). For you outpatient docs, the office visit codes are getting a 10% raise. Congratulations to all docs that see patients in the clinic (as a fee for service). I didn't delve into the article great enough to see how it would affect bundled payments to surgical services. I did see general surgeons realizing on average a 4% raise, mostly due to increased payment for practice expenses. You ED docs will see about a 2-3% raise in your ED codes.

Since all physicians who see patients (in fee for service) in the hospital bill hospital E&M codes , all physicians will see a raise. That includes you GI guys, you heart guys, you lung guys, you ID guys, you kidney guys. All of you will see a raise in your E&M fees. Those that do fewer procedures will see see a bigger raise than those that don't since the money to pay for these increased E&M fees is being redistributed from non E&M procedural codes. If you make most of your money on procedures, than you'll come out a loser. How you feel about that depends on how you make most of your money.

It's my opinion that procedures/surgeries, on a time based axis, pay far more than can be expected by the value placed on the education required to achieve their proficiency. But remember, it's all relative. How do you value what an EP ablation is worth compared to a level two hospital follow up? If you can't use education and time committment, then what. I have blogged extensively about these opinions. The fact that my central lines I do pay me 2-3x more on a time based axis than my hospital follow up codes says it all.

If I had my way, procedures would pay equivalently on a time based axis as E&M codes AND subspecialists would get the same E&M fees as the specialties of family medicine and internal medicine PLUS a defined premium based on years of training. For example, using three years as the defined residency experienced, those doing 4 year programs would get a 6% premium. Those doing a five year program would get a 12% premium. Those doing a six year program would get an 18% premium. Those doing a seven year program would get a 24% premium. The program length being defined as standard based on the subspecialty. and all procedures would be paid the same premium on the time based axis as the E&M codes. When bundling of care comes, you could make the same premium argument as well.

Instead of paying physicians to proceduralize you, we should be paying them to talk to you. I can assure you, if procedures were paid at the same rate as cognitive encounters, we would be doing a lot less intervening and a lot more thinking.

What do you think, should subspecialists be paid an E&M premium based on the length of their training track and allow the procedural fees to come in line with the E&M fees?

I Need A New Kidney, Oh Yeah, And You're Not My Son

An interesting scenario presents itself. You need an organ transplant, only to find out that your kid, who offered to give you one of his, he's not your biological kid. A discovery found in 1-3% of evaluations. So what do you do? Seems like it's a divided world out there.

Overall, 23% strongly agreed that the information should be shared; 24% strongly disagreed; and the rest were either mildly in favor, opposed or undecided. Of the potential recipients surveyed, 60% wanted to be told.

It seems like some institutions have taken the Don't Ask Don't Tell approach.

Many experts believe that the information should not be disclosed because it was not specifically sought, is not necessarily medically relevant and could be disruptive to the family. That said, experts advised transplant centers to develop policies on how to deal with these situations before they arise.

What do you think? Should you tell daddy he's not the daddy and should you tell the kid too?

Does America Have A Right To BASIC Health Care?

I hear it everyday. Affordable access to basic health care should be a right.

Could someone please define to me what constitutes basic in the basic health care arguement? I want to hear examples of what is basic health care and what would not be considered basic and why you have a right to one and not the other.

Why should we have a right to health care but not health? Should we not have a right to stay healthy? Should we not have a right to free gym memberships? How about a right to free vegetables. If you have a right to basic health care, we should also have a right to services that prevent the break down of health as well.

Right?

All The Risk, None of the Benefit

Da Boss over at DB's Medical Rants has a nice post titled "Deconstructing Quality". Let me give my scenario. In a two day span, I recently discharged four people whom I was asked to admit. What were they you ask?

1. An uninsured homeless drunk with a history of "seizure disorder", documented and witnessed pseudoseizures and a brief and transient episode of hypoxemia.
2. An uninsured patient with a new onset DVT of the leg.
   
3. An uninsured patient recently discharged from the hospital with chronic abdominal issues presenting with abdominal issues.
4. An uninsured patient with a focal superficial skin abscess I & D'd in the ED, who's symptom complex had been improving on a week of outpatient antibiotics.

Each patient presented with their own unique set of circumstances. Two of them had no desire to be admitted to the hospital. They happened to be uninsured, but even if they had insurance, the cost considerations remain.

In each case, I made sound scientific decisions that none of them required admission to the hospital. That either their pathology was not severe enough to warrant inpatient admission, that they did not meet inpatient criteria (even though I could make almost anyone qualify), or that they could be safely managed as an outpatient with appropriate available services.

How do you measure that quality? For the uninsured, I personally saved them thousands upon thousands of dollars that would eventually make it to a collection agency. I saved the hospital thousands upon thousands of dollars of nursing time, supplies, medications, and all the overhead/billing/administrative time and dollars that goes into the financial aspects of inpatient care. I saved your premium paying insurance companies and the Medicare National Bank thousands of dollars for not having to subsidize the expense of these uninsured patients who will never be able to pay their bills, even if they wanted to.

How do you measure that quality? And what's in if for me? I ask what's in it for me because to me, it's obvious. I carry all the downside risk of bad outcomes and none of the financial success in practicing cost effective care. I can understand clearly why defensive medicine is so prevalent in this legal climate we practice in. A climate where a bad outcome is considered negligence and standards of care have become irrational.

In every situation, I did a thorough evaluation. I based all my medical decisions on what I knew about the disease, what I knew about the patient's history and exam, what I knew about where they came from and where they were going. I based my medical decisions on sound clinical practice that would limit the possibility of a bad outcome.

But can I guarantee that the patient won't get worse? Of course not. Can I guarantee that drunk with transient hypoxemia doesn't have aspiration pneumonia that will present itself in 3 days? Can I guarantee that the stable as a rock patient with a DVT won't have a PE and sudden death in 18 hours? Can I guarantee that the patient with chronic abdominal complaints won't have a perforated colon tomorrow? Can I guarantee that the patient with the I&D who had been getting better for a week on antibiotics won't suddenly get septic and end up in multiorgan failure?

The answer to every one of these situations is no. I cannot guarantee a perfect outcome in any situation. Nor could I guarantee a perfect outcome in any of them even if they got admitted to the hospital. Even if I did everything right, the patient may still have a bad outcome. The way I see things, in this culture of blame, it's a lot easier for a jury to place blame on a physician for sending home a patient that gets worse than it is to place blame on a physician for a patient that gets worse in the hospital. The perception of negligence may be just that, a perception. But it drives medical decision making none the less. It drives defensive medicine like you wouldn't believe.

I took a risk. A major risk sending those four patients home from the ED. Is the risk real? Yes and no. No because I did the right thing using the scientific evidence and my clinical skills. Yes because it doesn't matter. It's easier for a jury to say the patient may have had a better outcome in the hospital than being discharged. If they get worse in the hospital you can blame it on the disease. If they get worse after being sent home from the ED, you can blame it on the physician. I mean, how could the physician be at fault when the patient gets worse inside the hospital, filled with all that expensive technology and 24 hour supervision? You get my drift.

In my medical opinion, using sound clinical medicine, every one of those patients deserved to be discharged from the ED. So why do I always get a brief uneasy feeling when I discharge someone from the ED. "What if they get worse?", I ask myself.

And then I have to keep reminding myself that nothing in medicine is 100%. They could get worse even if I admitted them and wasted thousands upon thousands of dollars that we will all pay for one way or another.

The problem is, even though the science is sound, a bad outcome drives risk, even though no negligence was performed. It's easy to find 10 doctors say the patient should have been admitted. It's just as easy to find 10 doctors who say the patient could have been safely discharged. The risk comes down to whether the defense or the prosecution put on a better dog and pony show.

By discharging these patients, I'm saying the standard of care is discharge. The ED doc is telling me, by asking me to admit the patient, that the standard of care is admission. Now, we docs set the standards. That standard should be based on science. Too often the standard of care is based not on science, but rather on fear.

And in these four patients, I take in all the risk discharging stable medical patients who could get worse and therefor be accused of negligence by not admitting a patient who the ED is telling me should be (their standard of care). And I get none of the benefit for saving America tens of thousands of dollars in expensive, unnecessary hospital care.

I'm not sure if I'm the exception or the rule for docs out there. I am doing my best to establish rational standards of care, one patient at a time. And I find myself going up against a huge wall of fear, a wall that is creating standards of care that are bankrupting our country and adding little to no additional benefit to patient care. Instead of calling it defensive medicine, you can call it what it really is, the the lawyer xray, lawyer CT, the lawyer MRI, the lawyer lab, the lawyer admission. That's what it is. Testing out of fear, not out of science. We physicians have created standards of care based on lawyer science, not doctor science.

I think I practiced quality care today. Quality that saved at least $20,000 in uncompensated care. How many HgbA1c's would you have to check to save $20,000? How many patients would you have to put on ASA to save $20,000? How many hearth failure patients would you have to have on ACEi to save $20,000?

The Medicare National Bank wants to give me 2% back for playing their PQRI games. How about putting PQRI in perspective. I saved us all $20,000 in uncompensated care using sound science, took all the risk in the eyes of a jury for discharging the patient home when the ED is telling me, by them asking me to admit, that the standard of care is to admit. And I get nothing to show for it.

All the risk and none of the benefit.

It's just easier to admit and spread the cost over 300 million Americans. And that is exactly the current state of American health care. You don't worry about the cost because someone else is paying for it. FREE=MORE

Time For A Happy Baby Picture

Two years old, Riyadh, Saudi Arabia. Looks like I'm going on a safari. I'm not sure which one is me though.

The New Era Of Disability

Dr Leap describes his experience with the new generation of disabled Americans:

All too often, my disabled patients complaints are as follows: ‘I hurt my back fishing. I hurt my leg on my four-wheeler, I fell off my horse, I fell off the roof, I got in a fight, I fell down when I was drunk at a party.’

Seems to me, if you can fish in a river, ride a four-wheeler, ride a horse, climb on a roof, get in a fight or drink heavily at a party, odds are you might just be able to hold down a job. Call me a hateful conservative, but that’s how I see it.

I had a young single female with three young kids once present to the hospital with "abdominal pain". I asked her what she did for a living. She said she was unemployed. I asked her what her source of income was. She said she was on disability. I asked her what her disability was (no outward signs of physical limitations)

"I'm poor and I have kids"

I talked with a colleague at Happy's hospital last month about her neighbor "on disability". A woman who's kid says things like "My mom's on disability." A culture of dependence nurtured and encouraged from crib to coffin. A lady that can be found daily bouncing on her trampoline. A lady who won't get married to her boyfriend because she will "lose her disability."

The neighbor lady asked my colleague if she would watch the house as they went on vacation for the week . The colleague turned her in. As a pissed off tax payer she called authorities to let them know her neighbor was ripping us off. Soon enough, the neighbor could be found hobbling around with a knee brace, and the boyfriend was nowhere to be found .

Welcome to America. Where 99 trillion dollars buys your vote and being a mother makes you disabled and jumping around on a trampoline and taking vacations on your tax dollar is considered normal for this new era of disability.

I'm considering applying myself after experiencing muscle aches after a five mile jog. I figure I've got a pretty good chance of cashing in on other peoples money.

Can Hospitals Survive a $155 Billion Dollar Haircut?

The hospitals have agreed to not get paid $155 billion dollars from Medicare/Medicaid over the next ten years as part of an agreement with Obameconomics. Let's do a quick math scan on the numbers.

How much will this cost the hospitals?

• $155 Billion dollars over ten years
• That's 15.5 Billion dollars per year
• There are about 7,500 hospitals nation wide
• On average that means the average hospital will forego 2.1 million dollars a year in payments.
• Operating margins of hospitals run about 4%. That means while your care is horribly expensive, they only make 4% on your the insurance cash they are paid.
• That means a hospital would have to generate 51.6 million dollars a year in revenue to just break even for losing their 2.1 million dollars a year.
• 
  

Let's look at it another way. Total health care expenditures in the US are about 2.4 trillion dollars. 35% of that is spent on hospitals. That's 840 billion. Government insurance (Medicare/Medicaid) is about 1/2 (let's assume 50% for easy math) of that expense. That's 420 billion dollars a year spent on hospital care by your government (state and local). If hospital margins run about 4%, that means hospitals profit to the tune of 16.8 billion dollars a year.

ADDENDUM (math error) Math Correction: Let's assume they profit 4% on their revenues of 840 billion dollars. That means yearly hospital profits on 4% margins is 33.6 billion dollars. Cut 15.5 billion from government cuts and you're left with profits of 18.1 billion dollars or 2.1%, assuming private insurance pays the same as public, which we all know it doesn't.

You can't cut 15.5 billion dollars of profit a year out of hospital care when they are only making 33.6 billion a year. Your margins would be cut from 4% to 2.1% percent.


One of two things will happen.

1. Hospitals must reduce costs to increase their operating margins.
   
2. Increase other sources of revenue (private insurance will go up, which means all our premiums will go up, which means private insurance will not be able to compete with any government plan that pays less than cost.)

How do you reduce costs?

1. You fire people and make those that remain work harder, perhaps increasing the work load of understaffed nurses, respiratory therapists and lab technicians trying to operate under an ever larger bureaucratic mess.
   
2. You pay them less, there by guaranteeing a mass exodus out of the medical field for everyone who works in hospitals, making the situation even worse.
3. You reduce services. Can't run that MRI? Can't do that lab in house? No RT in the middle of the night? No echo on week end nights? Need an endoscopy tech in the middle of the night, you'll have to transfer 300 miles down the road.
   
4. You delay capital expenditures. It's too bad that CT scanner broke again. Your head bleed cannot be confirmed tonight.
   
5. You cut corners on maintenance. No oxygen for the third and fifth floors. We haven't gotten around to fixing the lines.
   
6. You offer fewer drugs. I'm sorry sir, we don't offer that chemotherapy at this hospital.
   
7. Less research and development. This factor alone will kill medicine in the US.
   
8. Fewer quality initiatives. It takes money to generate quality. If you don't pay for quality, you get what you pay for.
   

Unless you can reduce the cost of doing business (deregulate the hospital industry) there is no way I see hospitals surviving a 15.5 billion dollar per year haircut, leaving operating margins of only 2% per year. With out deregulation, the hospital industry will screw all of us because they will have to just to survive. Unless they increase their revenues from other sources.

What does that mean to me and you? It means all of us not on the take with government health insurance will surely see higher premiums as hospitals look to the private insurance companies to survive. In essence, what Obama has done is increase the tax on all Americans who get their health insurance from private industry. He has, once again, created a stealth tax on every middle class American in this country. Because every additional dollar your employer spends on your health insurance is one less dollar you get in wages.

Eventually, once the government has undercut the true cost of health care by defraying more and more real costs onto the private industry, Americans will eventually revolt, calling for a take over of their health care by the "cheaper" government options. Cheaper not because the government can provide cheaper care, but because they defray the true cost onto private industry. But what happens when there is no private industry left to shoulder the burden of lowballing government care? We will be left with Obameconomics, where the true cost of health care will present itself. If there is no private industry left to subsidize the false economies of Obameconomics, we are all screwed. Because American health care cannot surivie on Medicare/Medicaid for all.

And folks, the only way a hospital can survive on a Medicare/Medicaid for all, in this current regulator environement is to do any of the the eight things I talked about. If you want Medicare/Medicaid for all, and the false cost that comes with it, be prepared to

1. Wait for your care
2. Not get your care at all
   
3. Or get crappy care for all.

And that's a fact. There is no way around it. 4% margins tell the story. 2% margins cannot survive without a private industry bailout (me and you through higher premiums tax

The government give ith and the government taketh away.

Tax Credits To Breast Feed?

Pumping for dollars.

ObamaCare Emergency Help Line

Here's the end of it:


Enter your age, followed by the pound sign.

7 4 #

I'm sorry, the maximum age of treatment for this condition, as determined by Federal Coordinating Council for Comparative Effectiveness Research is Seventy-three. Thank you for calling.

Good-bye.

7 2 # ... 7 2 # ... 72 #

*** Click ***

[Call recording terminated]

Go read the beginning

The Debt Star

Let's Pray...

via Doug Ross @ Journal

Look Before You Lick

Tis a strange world we live in. Warning. This is gross

What Are The Minimum Requirements To Be A Black Jack Dealer?

Details. Details. Details.

Should An Ambulance Charge More For Fat People?

That's exactly what American Medical Response, an ambulance service in Topeka, Kansas is planning on doing. If you weigh more than $350, plan on paying an extra $543. The extra cost is justified by the extra equipment required to transport morbidly obese patients.

An ambulance ride with American Medical Response in Topeka, Kansas will soon cost an extra $543 for folks weighing 350 pounds or more. Though AMR already owns cots that can support up to 500 pounds, they claim that because of rising demand from so-called "bariatric patients," they now need to buy winches and "extra large and reinforced cots."

Of course, this only applies to those with private insurance, and probably those without any insurance. I find it interesting that Medicare won't pay more, considering that I am asked by the in house hospital chart police to document "morbid obesity" on patients that meet that criteria. I can only assume it's because documenting morbid obesity is considered a complicating illness or major complicating illness that increases the overall payment a hospital gets for its diagnosis related group (DRG).

So what do you think? If airlines charge fat people for an extra seat, should an ambulance be able to do the same?

Eliminate Consultation Codes And You'll Get Unintended Consequences

As you know, CMS dropped a bombshell the other day onto the physician community by suggesting they are going to eliminate consultation codes from the Evaluation & Management (E&M) arsenal. If you've been reading anything over the last 20 months, you will know I find myself highly knowledgeable about the coding system that is the disdain of physicians everywhere.

Consultation codes exist in both the inpatient and outpatient spectrum of care. For inpatients, there are five of them, CPT codes 99251-99255. For out patients, there are five of them as well, CPT codes 99241-99245. A consult generally requires the 3 Rs.

• Request. You must document the requesting physician
• Reason. You must document the reason for the consult
• Response. You must respond (usually a carbon copied dictation) to the requesting physician

If we get rid of consult codes, be prepared to lose the 3 Rs. That may or may not be a good thing depending on your view of excess documentation requirements and built in inefficiencies of E&M.

You can see much more here in my coding lectures or earn CME at E&M University.

I am going to go out on a limb and suggest that the elimination of consultation codes is just the beginning. I am going to suggest that CMS ultimately has the entire elimination of the Evaluation & management fee for service system on the chopping block in an effort to move toward bundled care schemes for all physicians which will pay physicians to take care of patients, not encounters with patients.

With that said, I wonder how much money will be saved and redistributed from eliminating consultation codes. And I might suggest that eliminating consultation codes could increase overall costs due to unintended consequences. Based on their news release I can't figure out They are going to allow admission codes (99221-99223) to substitute for the consultation codes they are removing (99251-99255).

Let's look at the inpatient codes: Let's assume every in patient consult that is done meets level five criteria. In my state a level five consult code (the highest/99255) pays about 5.5 RVUs or $190. A level three admission code 99223, the requirements of which are identical to the 99255 consultation code pays about 5 RVUs or $170 dollars. That represents a savings of $20 per consult if consultation codes were substituted with admission codes .

CMS will allow consultants (that includes me too when I'm being asked to evaluate subspecialist patients in the consultation role) to use the admission codes when asked to evaluate a patient. But, if they only allow us to use the hospital follow up codes (99231-99233), an equivalent level three hospital follow up code (99233) pays just over 2.5 RVUs, or $90. That's less than 50% of the high level consult code that pays $190

As you can see, the savings could be anywhere from just over 10%-50%, depending on which codes are considered "existing". And this savings would be redistributed into the existing E/M codes to increase payment rates.

CMS is also proposing to stop making payment for consultation codes, which are typically billed by specialists and are paid at a higher rate than equivalent evaluation and management (E/M) services. Practitioners will use existing E/M service codes when providing these services instead. Resulting savings would be redistributed to increase payments for the existing E/M services.

What that means is all doctors who do E&M follow up or admission codes will experience a raise. That includes the subspecialists as well, since most of them continue to follow along on a daily basis once the initial consult is done. I do not think this represents a significant reduction in physician payment for subspecialists, because more will be collected on the follow up codes.

You can see much more here in my coding lectures or earn CME at E&M University.

However, the unintended consequences of this action may make physicians stay on board in a consultation role for periods of time longer than is medically necessary thereby increasing total overall costs. And nobody can tell you when signing off is appropriate. This is done on an individual basis based on the patient and the physician. It will always meet medical necessity muster. I have never been denied payment because I didn't sign off a case soon enough. I blog always that I could create medical necessity out of thin air. It is a utopian concept that can not be codified or quantified. My service was medically necessary because I said it was. That is essentially the standard.

When a physician "signs off" a case is completely arbitrary. As a hospitalist, I have patients being followed for weeks by subspecialty consultants who add nothing of significant value on a daily basis. If the consultation codes are removed, it may mean a further delay in signing off the case, especially if those codes are paying a higher rate. And that folks means higher costs for everyone, including the Medicare National Bank.

Lets look at the outpatient model. The highest outpatient consult (99245) in my state pays just over 6 RVUs or $210. There is no equivalent admission code for an outpatient consult. The closest equivalent is a high level outpatient follow up visit (99215) which pays 3.5 RVUs, or just under $120. A significant reduction in fee. Since I don't work in outpatient medicine, perhaps those of you still reading this far could comment on what affect that would have on patient care. By nature, a consultant needs either a referral from a family medicine doc or an internist, or a self referral from a patient. How will this affect a consultants mindset in outpatient care?

Ultimately, every action has a consequences. In this fee for service system we live in, every action will drive volume, which drives revenue, which drives income, which in our capitalistic society, will attempt to buy happiness. Which we all know, at least I do, will never happen.

You can see much more here in my coding lectures or earn CME at E&M University.

What Is The Best News Headline Ever?

Wrestling Midgets Killed By Fake Hookers

What a strange world we live in.

When's The Last Time

You did this

Imagine if it was a billable procedure that paid well. Physicians would be pushing nurses out of the way for the opportunity.

Are Hospitalists Necessary To "Follow Post Op"?

I suggested lightheartedly that hospitalists would be required to consult for pain management on surgical patients who's doctors have never learned to prescribe anything but Percocet and Vicoden, two drugs which may have seen their last days. The conversation got off track with this anonymous subspecialist comment, but I thought it raised some important issues to discuss.

Anonymous said...

I'm curious Happy.

Don't you make a living by seeing the "Specialist's" patients?

I don't mock the internists when they send me common things that they could treat....I figure they are happy to see my general medicine patients post op.

Am I wrong?

Yes, you are. and here's why...

You Know Your Nation Is In Deep Financial Trouble

When the Amish default on their loans.

"People wanted bigger weddings, newer carriages," Mr. Lehman says. "They were buying things they didn't need." Mr. Lehman spent several hundred dollars on a model-train and truck hobby, and about $4,000 on annual family vacations, he says. This year, there will be no vacation.

Some one help us all.

When Homeopathy Meets the Emergency Department

Funny stuff (from Boing Boing) video below

Dixie Normous

see more Fail Blog

Any other good ones out there?

Cross Country Slogan Of The Year

see more Fail Blog

The cross country slogan of the year. That's terrible. From a high school yearbook none the less.

It's Always Nice To Get a Thankyou

I got a nice letter in the mail the other day. A thank you card written by one of Happy's hospital staff. It said:

Dear Dr Happy,

When I rounded on Mr and Mrs Patient yesterday they shared with me just how impressed they were with you and the time you spent with them explaining everything to them. They were very pleased with their stay and they usually go to the Hospital on the Lake. So because of your excellent care they have a great respect for our hospital. Thank you.

It's amazing how much quality you can generate by spending time with the patient. The thing with many patients is they don't know Jack from Jill when it comes to appropriate health care decision making. My patient population is probably like every other population in this world. And most don't know a thing about disease management. Sure you can read a life time about diseases on the internet, but for many, it's impossible to tie it all together. It takes an incredible amount of personal sacrifice from patients to understand their illness. And most are not willing or able to do so. A lot will simply do what the doctor says.

I could have told them anything, including bad information, but If I spend time with them I get letters telling me thank you for being a great doc.

Unfortunately, in this payment model we all live in, the more time you spend talking, the less likely you are to survive financially. It is simply not the way things are done in the third party fee for service model.

Why Are MD Salaries So High?

Dr Perry at Carpe Diem suggests it is the Medical Cartel. Dr Perry seems to have forgotten about RVU/RUC/SGR economics. It doesn't matter if there are two physicians or 200 million physicians in this country, there is no market pricing of their services. All we have is a government monopoly that signs off on the RUC cartel which establishes the value of all physician services in this country. And that has nothing to do with how many medical students or residency slots there are.

One explanation is the restriction on the number of medical schools, and the subsequent restriction on the number of medical students, and ultimately the number of physicians.

How To Cure Health Care

By Milton Friedman, 2001. An excellent read. Here's an excerpt:

The ideal way to do that would be to reverse past actions: repeal the tax exemption of employer-provided medical care; terminate Medicare and Medicaid; deregulate most insurance; and restrict the role of the government, preferably state and local rather than federal, to financing care for the hard cases. However, the vested interests that have grown up around the existing system, and the tyranny of the status quo, clearly make that solution not feasible politically. Yet it is worth stating the ideal as a guide to judging whether proposed incremental changes are in the right direction.

My guess is we are heading in the wrong direction. I mean, we are already 99 trillion dollars in the hole. What's another 2 trillion dollars if you can buy off your constituents. Right?

via Cafe Hayek

Should Patients Be Equal Partners In Their Health Care Decisions?

Especially when they lack the ability to understand basic health concepts. Such as, Where is your heart located?

The 722 people who took part in the study were shown pictures of the human body (male or female) with certain areas shaded out and were asked which of the shaded areas was the location of a given organ. Although 85.9% of people could identify the location of the intestines and 80.7% knew where the bladder could be found, only 46.5% of people correctly identified the heart and 68.6% misidentified the position of the lungs.

Can you imagine trying to explain the pathophysiology of stable vs unstable angina vs NSTEMI vs STEMI to 75 year old retired lady who can't even tell you where the heart is located. In this day and age where conversation is uncompensated and technology is viewed as the savior of our health care needs, it's no wonder why it's just easier to talk fast, sound important and recommend "tests" that make loud beeps, take fancy pictures and cost a lot of money, paid for by the Medicare National Bank. Perception is 90% of reality. And who's going to question the doctor when you don't even know where the heart is?

via Booster Shots

Home Made Fire Alarm

That's just good humor

Why Is The NIH Funding Chelation Therapy?

Because politicians in high places say so. This is what happens when lawyers politicians interfere with scrupulous science. This is why you should be very afraid of government controlled health care. Politics will always trump science.

All evidence seems to suggest that political meddling managed to trump science in this case - putting the lives of 2000 study subjects at risk, without any likely benefit to them or medicine.

I had a patient once who sweared by chelation therapy for his coronary artery disease. All I could do was nod my head, uh huh uh huh, and smile. He couldn't understand why the clinic got shut down.

Are The Consequences of Drug Prohibition Worse Than The Drugs Themselves?

A great read over at Bad Science. I love the last paragraph.

Drugs instantiate the classic problem for evidence based social policy. It may well be that prohibition, and the inevitable distribution of drugs by criminals, gives worse results for all the outcomes we think are important, like harm to the user, harm to our communities through crime, and so on. But equally, it may well be that we will tolerate these worse outcomes, because we decide it is somehow more important that we publicly declare ourselves, as a culture, to be disapproving of drug use, and enshrine that principle in law. It’s okay to do that. You can have policies that go against your stated outcomes, for moral or political reasons: but that doesn’t mean you can hide the evidence, it simply means you must be clear that you don’t care about it.

So much of what government does follows blindly in the face of not caring about the evidence. For example the evidence suggests we are 99 trillion dollars in the hole, and yet we want to keep spending more. That's because the role of today's government has far exceeded its original necessity and it establishes laws often times solely to justify its own existence and to guarantee its own survival.

The amount of destructive pathology I see as a hospitalist physician due to alcohol and tobacco easily outnumbers the patients I see for illegal narcotic complications by 100 to one. And that's being generous. It's time for change and hope we hear so much about. It's time for less talk and more action. It's time for evidence to guide your policy, or at least admit you don't care about the evidence.

Is It OK For Hospitals To Pay Physicians To Be On Call?

An advisory opinion by the Department of Health and Human Services Office of Inspector General says yes.

In the May 21 opinion, OIG acknowledged that hospitals increasingly are compensating physicians for emergency coverage. "We are mindful that legitimate reasons exist for such arrangements in many circumstances," including a scarcity of available doctors in particular areas and compliance with the federal Emergency Medical Treatment and Active Labor Act.

Many hospitals already pay hospitalists subsidies for their inpatient duties, one of which is to take care of unassigned uninsured patients. Perhaps the AMA believes hospitalists have an ethical obligation to provide charity care to these patients.

I have a different suggestion. If it's OK for hospitals to pay physicians to be on call in order to maintain compliance with EMTALA rules, shouldn't it be the US government and not the hospitals who are fitting the bill for the uninsured being treated under EMTALA rules? Any lawyers out there want to take on the federal government? It could perhaps save your life one day when you need a doctor to care for you, but everyone is at home sleeping.

Which Medical Specialty Has The Highest Acceptance Of Credit Cards?

You probably guessed plastic surgery. You are correct, at 91%. Internists are just over 50% Pathologists round out the bottom at 21%. However, the trend is apparently less, not more acceptance. The interchange fees can run 3-4%, which cuts into the physician's bottom line. I find the lack of acceptance of credit cards hard to believe.

At a 4% fee, if you increased your collection rate by just one patient out of every 25, you would come out ahead, not even including the billing expenses incurred from unpaid balances. It takes increasing your collections on just one patient a day in a 25 patient per day clinic to come out ahead. And it's easier to collect a $100 "outstanding balance" on credit card than it is to ask for $100 in cash.

Do Physicians Have An Ethical Obligation To Provide Charity Care?

In interesting discussion in the AMA. It appears they feel physicians have an ethical obligation to provide care, regardless of the patient's ability to pay.

So long as it is fiscally sustainable for physicians, the policy says, doctors should accept uninsured patients and maintain relationships with patients who lose health coverage. Doctors should help patients access public programs and charitable sources. They should take part in the political process to cut financial obstacles to health care access, delegates said.

A very noble policy to institute. To bad nobody can define "fiscally sustainable". For some physicians that might mean $100K a year in income. For others that might mean $1 million. It is not for anyone to judge what is fiscally sustainable for a physician's lifestyle. That is a personal decision only the physician and their family can answer.

Of course all would be fine and dandy if the grocery store down the street accepted the smiley faces and fuzzy snuggles as payment in full that you receive from your ethical obligation to nonpaying patients.

The AMA has it all wrong. Physicians have always been a very charitable group of folk. Not because of an ethical obligation dictated by an organization that has lost its way through the years, but rather out of a self inflicted viral desire to help others, on their own terms. Mandating charity as an ethical obligation is the same as mandating all physicians accept Medicaid or Medicare. That makes you a slave of society.

As practicing physicians who operates under the US monetary system we are bound to play by capitalism's rules. Your landlord does not care about your ethical obligation to provide charity care. Your kid's dentist does not care about your ethical obligation to provide charity care. Your accountant and lawyer do not care about your ethical obligation to provide charity care.

Whether to be charitable or not is a very personal decision. One that cannot be codified into ethical mandates from aging institutions. If you as a physician lose your ability to provide free care on your own terms, based on your own value system, you become nothing more than a slave of society. An ethical mandate devalues your years of training to nothing more than a societal right. A right that places you in a position slavery and not one of free will to provide charity on your own terms. The fact that the AMA feels an obligation to codify the ethical obligation to charity says to me how out of touch they are with the realities of the economics of today's medicine.

The new policy comes when declining physician income appears to be affecting the amount of charity care doctors provide. A March 2008 Milbank Quarterly report found doctors' pay fell 7% from 1996 to 2005, when adjusted for inflation. In the same period, the proportion of doctors offering charity care dropped 10% to about two-thirds of physicians

Physicians are saying, that their ability and or desire to provide charity care is inversely proportional to the financial situation they find themselves in. It has nothing to do with ethical mandates and everything to do with personal financial decisions. If you want more physicians to provide more charity care, you're going to have to pay them more to do so. And that has nothing to do with ethics and everything to do with economic common sense.

What Are The 25 Top Priorities For Comparative Effectiveness Research?

The American Recovery and Reinvestment Act of 2009 called on the Institute of Medicine to recommend a list of priority topics to be the initial focus of a new national investment in comparative effectiveness research. The IOM’s recommendations are contained in the report, Initial National Priorities for Comparative Effectiveness Research. via (Kaiser Health News)

There are 100 priorities, divided into four quartiles. The first quartile carries the highest priorty. In no specific order, here are your top 25 priorities for CER.

1. Compare the effectiveness of treatment strategies for atrial fibrillation including surgery, catheter ablation, and pharmacologic treatment.

2. Compare the effectiveness of the different treatments (e.g., assistive listening devices, cochlear implants, electric-acoustic devices, habilitation and rehabilitation methods [auditory/oral, sign language, and total communication]) for hearing loss in children and adults, especially individuals with diverse cultural, language, medical, and developmental backgrounds.

3. Compare the effectiveness of primary prevention methods, such as exercise and balance training, versus clinical treatments in preventing falls in older adults at varying degrees of risk.

4. Compare the effectiveness of upper endoscopy utilization and frequency for patients with gastroesophageal reflux disease on morbidity, quality of life, and diagnosis of esophageal adenocarcinoma.

5. Compare the effectiveness of dissemination and translation techniques to facilitate the use of CER by patients, clinicians, payers, and others.

6. Compare the effectiveness of comprehensive care coordination programs, such as the medical home, and usual care in managing children and adults with severe chronic disease, especially in populations with known health disparities.

7. Compare the effectiveness of different strategies of introducing biologics into the treatment algorithm for inflammatory diseases, including Crohn’s disease, ulcerative colitis, rheumatoid arthritis, and psoriatic arthritis.

8. Compare the effectiveness of various screening, prophylaxis, and treatment interventions in eradicating methicillin resistant Staphylococcus aureus (MRSA) in communities, institutions, and hospitals.

9. Compare the effectiveness of strategies (e.g., bio-patches, reducing central line entry, chlorhexidine for all line entries, antibiotic impregnated catheters, treating all line entries via a sterile field) for reducing health care associated infections (HAI), including catheter-associated bloodstream infection, ventilator associated pneumonia, and surgical site infections in children and adults.

10. Compare the effectiveness of management strategies for localized prostate cancer (e.g., active surveillance, radical prostatectomy [conventional, robotic, and laparoscopic], and radiotherapy [conformal, brachytherapy, proton-beam, and intensity-modulated radiotherapy]) on survival, recurrence, side effects, quality of life, and costs.\

11. Establish a prospective registry to compare the effectiveness of treatment strategies for low back pain without neurological deficit or spinal deformity.

12. Compare the effectiveness and costs of alternative detection and management strategies (e.g., pharmacologic treatment, social/family support, combined pharmacologic and social/family support) for dementia in community-dwelling individuals and their caregivers.

13. Compare the effectiveness of pharmacologic and non-pharmacologic treatments in managing behavioral disorders in people with Alzheimer’s disease and other dementias in home and institutional settings.

14. Compare the effectiveness of school-based interventions involving meal programs, vending machines, and physical education, at different levels of intensity, in preventing and treating overweight and obesity in children and adolescents.

15. Compare the effectiveness of various strategies (e.g., clinical interventions, selected social interventions [such as improving the built environment in communities and making healthy foods more available], combined clinical and social interventions) to prevent obesity, hypertension, diabetes, and heart disease in at-risk populations such as the urban poor and American Indians.

16. Compare the effectiveness of management strategies for ductal carcinoma in situ (DCIS).

17. Compare the effectiveness of imaging technologies in diagnosing, staging, and monitoring patients with cancer including positron emission tomography (PET), magnetic resonance imaging (MRI), and computed tomography (CT).

18. Compare the effectiveness of genetic and biomarker testing and usual care in preventing and treating breast, colorectal, prostate, lung, and ovarian cancer, and possibly other clinical conditions for which promising biomarkers exist.

19. Compare the effectiveness of the various delivery models (e.g., primary care, dental offices, schools, mobile vans) in preventing dental caries in children.

20. Compare the effectiveness of various primary care treatment strategies (e.g., symptom management, cognitive behavior therapy, biofeedback, social skills, educator/teacher training, parent training, pharmacologic treatment) for attention deficit hyperactivity disorder (ADHD) in children.

21. Compare the effectiveness of wraparound home and community-based services and residential treatment in managing serious emotional disorders in children and adults.

22. Compare the effectiveness of interventions (e.g., community-based multi-level interventions, simple health education, usual care) to reduce health disparities in cardiovascular disease, diabetes, cancer, musculoskeletal diseases, and birth outcomes.

23. Compare the effectiveness of literacy-sensitive disease management programs and usual care in reducing disparities in children and adults with low literacy and chronic disease (e.g., heart disease).

24. Compare the effectiveness of clinical interventions (e.g., prenatal care, nutritional counseling, smoking cessation, substance abuse treatment, and combinations of these interventions) to reduce incidences of infant mortality, pre-term births, and low birth rates, especially among African American women.

25. Compare the effectiveness of innovative strategies for preventing unintended pregnancies (e.g., over-thecounter access to oral contraceptives or other hormonal methods, expanding access to long-acting methods for young women, providing free contraceptive methods at public clinics, pharmacies, or other locations).

Go check out the other 75.

Happy Fourth Of July

I heard a lady blew off half her face yesterday with a home made "firework".

Here's a safe way to celebrate.

via Carpe Diem

How Much Could A Private MRI Cost?

In Canada patients tired of waiting are going out of the government health care Q's and paying out of pocket. I blogged earlier about the truth about Canadian medicine.

As the Obama administration prepares to launch its legislative effort to create a national health care system, many experts on both sides of the debate site Canada as a successful model. But the Canadian system is not without its problems. Critics lament the shortage of doctors as patients flood the system, resulting in long waits for some treatment. "No question, it was worth the money," said Crossman, who paid several hundred dollars and waited just a few days.

Several hundred dollars cash? That's interesting. It'll cost you a at least a couple grand if you try to get one here. I wonder why that is. Perhaps there is no competition?

My Universal Access In A Market Based Health Care System

Obama admitted that government intervention into the pricing of health care is playing a huge role in the cost of care we are receiving.  I agree.  We are getting exactly what we pay for.  Third parties have tried, and failed, to price health care accordingly.  The unintended consequences has been a high cost, low value, do more mentality that his driven  up the overall cost of care.  The consequences of price control will always be to increase the volume of services, in a fee for service model, until the revenue recovers.  Health care will always be a growth industry.  The question is, how is our government going to fiscally survive the inevitable. We are 99 trillion dollars in the hole in unfunded entitlements.

May I offer one suggestion that creates WIN-WIN while aligning all the forces:  A hybrid system that incorporates universality and personal financial responsibility and gives incentives to government, physician, patient and hospital alike to take care of patients for the right reasons, while making sure everyone has access to life saving health care.  It is a  common sense approach to health care financing.  And it is based on your adjusted gross income for the previous fiscal year ending April 15.  Happy's utopia for a hybrid universal market based health care finance system.

1. Determining Your Healthcare Tier:  The financial responsibility for you and your families health care will be determined by your adjusted gross income (AGI) for the fiscal year ending April 15th.  You and your dependents, as determined by your income tax filing, will receive a plastic ID card, indicating your tier of participation.  That tier, one of six, will be determined by your AGI above the federal poverty guidelines.    For example, the federal poverty level for a family of 4 is $22,050.  For every 100% above that income level, you achieve a higher tier. See the following example for AGI of a family of four:

Tier 1:     0-$22,000

Tier 2:  $22,001-$44,000

Tier 3:  $44,001-$66,000

Tier 4:  $66,001-$88,000

Tier 5:  $88,001-$110,000

Tier 6:  $110,000+

   2.  Universal Access means the US government will pay a defined fee for every CPT code,or a defined fee for a bundled service.  It really doesn't matter if the payment if bundled or fee for service.  The government will  pay no more than its defined maximum for the year.    And every American receives the same benefit.   The US government will decide, based on its own solvency how much that fee is.  It is the ultimate capitated government health care system.  Think Medicaid for all.  If the pot of money decreases, the payment rates will  decrease as well.    That means it cannot go unfunded.  Base payment rates will rise and fall with the state of the economy.  It is an entitlement mentality, but one that will never bankrupt our country.  This sounds like a terrible idea (Medicaid for all) until you consider the rest of my proposal.

    3.   Market Prices.  The provider of service, (a physician, hospital, pharmacy, HHC agency etc...) are free to charge market prices in a bid to compete with our providers on quality and cost.  For example  Dr Smith, a cardiologist can charge $300 for a new office visit.  Dr Jones, a competing cardiologist can charge $400 if he feels he offers a greater service.  In either case, both physicians are competing on price.  The universal Medicaid for all government system may only pay $50 of that office visit.  So how does the physician collect what he feels his service is worth?  Well, how much you as a patient owe your physician (above what the government will pay) will depend on what tier you are in.  Here is my proposal on how much you would owe your physician.

Tier 1:  The patient owes nothing.  The government would pay both physicians $50.

Tier 2:  20% of market fee minus government rate.  For Dr Smith that means ($300-$50)*.2=$50 .  For Dr Jones that means ($400-$50)*.2=$70

Tier 3:  40% of market fee minus government fee.  For Dr Smith that means ($300-$50)*.4=$100.  For Dr Jones that means ($400-$50)*.4=$140

Tier 4:  60% of market fee minus government fee.

Tier 5:  80% of market fee minus government fee.

Tier 6:  100% of market fee minus government fee. That means, what ever the government doesn't pay, the patient is responsible fully for the rest of the market based fee being charged by the physician.

What this does is encourage all providers, whether it's doctors or hospitals to compete on quality and price to drive patients to them rather than their competitors.  If you are a tier 3 patient and you had the choice between paying $100 or $140 it is up to you to decide whether you want to pay the extra dollars to keep Dr Jones rather than switching to Dr Smith.  If you feel Dr Jones is worth the extra $40, you may decide to pay the extra money and stay with him.

Some folks may suggest that having unlimited price potential is dangerous for patients.  And it potentially is, except when you consider my proposals further.

  4.  Automatic Deductible.  Every American has an automatic 4% withdrawn tax free from their paychecks and deposited into an account, to be used for all their health care needs.  Your deductible is determined by your tier, but shall remain at 4% for all tiers.

Tier Deductible

Tier 1:  No deductible.  The government pays for everything

Tier 2: $880-$1,760 (this is 4% of your AGI)

Tier 3: $1,761-$2,640 (again 4% of your AGI)

Tier 4: $2,641-$3,520

Tier 5: $3,521-$4,400

Tier 6: $4,401- unlimited.

If you make 10 million dollars a year in AGI, your deductible for your family would be $400,000 a year.  I  suggest that 4% of AGI, tax free in and tax free out, is a reasonable contribution to ones own health care needs.  This takes FREE=MORE out of the equation and places some reasonable personal financial responsibility into the equation.  The contribution is required.  Everyone in this country with an AGI of greater than the poverty level is required to contribute to their own health care needs.  But what happens if you reach your deductible for the year?  Who pays then?

5.  Post Deductible Dollars.  All employers are required to purchase post deductible insurance for their employees.  If you are unemployed or retired disabled, the government will purchase the insurance for you on a prorated basis, based on your AGI.    How much the insurance company pays the providers of care will be determined by the patient's tier with the same percentages applying.  Let us imagine a hospital charging $20,000 for your hospital stay.  I would imagine a lot more transparency in pricing if hospitals were forced to compete on price and a lot of the ridiculous pricing would disappear.  How much would the private insurance company pay if you got a $20,000 hospital bill?

Let's imagine Medicaid for all paid $3,000.  That leaves $16,000 to be paid for.

Tier 1:  The government would pay nothing more than $3,000.  Since there are no deductibles for the patient to pay, there is no private insurance payment.  Payment in full is $3,000

Tier 2:  The government would pay $3,000 (to guarantee universal access, it must be cheap), the patient would pay 20% of the remaining $17,000 up to a maximum $1,760.  That leaves $20,000-$3,000-$1,760=$15,240.  That means the private insurance company would be responsible for 20% of $15,240, or $3,048.  Total bill paid $7,808  on a $20,000 market price hospital stay.

Tier 3:  The government would pay $3,000.  The patient would pay 40% of the remaining $17,000 up to a maximum of 4% of AGI ($1,761-$2,640).  That means the private insurance company would be responsible for 40% of $20,000-$3,000-$2,640, or $5,744.  The total bill paid would be $11,384.

Tier 4:  Government would pay $3,000.  The patient would pay 60% of $17,000 up to a maximum of $3,520.  The private insurance company would be responsible for 60% of $20,000-$3,000-$3,520, or $8,088.  Total bill paid to the hospital would be $14,608.

Tier 5:  Government would pay $3,000.  The patient would pay 80% of $17,000 up to a maximum of $4,400.  The private insurance company would be responsible for $10,080.  The total bill paid to the hospital would be $17,480

Tier 6:  Government would pay $3000.  The patient would pay 100% of $17,000 up to a maximum of 4% of their AGI.  Potentially the private insurance company would pay nothing, if the patients income was great enough.  Hospital collects $20,000

You might read this and suggest that hospitals and providers may simply build in rich areas or close down in poor areas, or doctors may turn away poor folk.  You'll have to read on to understand why that wouldn't happen.

6.  Earning Cash Back.  Since deductibles are determined yearly by your adjusted gross income and you are required to contribute 4% every year to your account and since your maximum out of pocket per year is 4%, what happens to your dollars if they are not spent?  Good question.  You cannot purchase other goods and services with your health care deductible dollars,  but you can sell them back to the private insurance market   These deductible vouchers (as good as cash to the insurance companies), sold to insurance companies (EBAY style auction) at discounted rates  can be used by private insurance companies to keep their costs down.  If you had $3,000 in unused pretax health care dollars, you may get $2,000 in cash by selling your health care dollars to your private insurance company, who can then use it to subsidize their premiums.  Once again, the healthy are subsidizing the unhealthy by helping to keep private premiums down.  And the money patients earn from selling their unused deductible dollars is tax free as well.  And can be used for anything.  Patients have an incentive to shop around for the lower priced physicians, the lower priced radiology suites, the lower priced hospitals to get their elective procedures.  They have an incentive to remain healthy, to stop smoking and exercise.  If they can prevent their own illness, they have an opportunity to recover a percentage of their  deductible dollars.  Private insurance companies may use their voucher money to offer lower cost premiums or to offer programs to keep their premium payers out of the hospital.

7.  It pays to take care of poor people.  What's to keep hospitals from only building in rich neighborhoods.  What's to keep physicians from only filling their clinics with rich people?  Well, first of all,  if most of the population was rich, we wouldn't be having this discussion.  That's not to say there aren't rich and poor neighborhoods.  There are.  But as it stands now poor people don't pay anything and rich people don't pay their fair share.  That's why I would propose minimum standards for the number of Tier 1 or Tier 2 patients.  If these minimum standards were not met, no physician in that practice  (or hospital for that matter not seeing enough poor people) would receive any payment of any kind from the US government.  That would free up money to increase payments to other physicians and hospitals who do see a fair number of Tier 1 or Tier 2 patients.  And the higher your percentage of Tier 1 and Tier 2 patients in your practice, the more the government would give you for all your patients, including Tier 6 patients as well.  In other words, If Dr Jones had no Tier 1 patients in his clinic or if his hospital on the lake had  very few Tier 1 patients neither would get the $50 for the clinic visit or the $3,000 for the hospital stay, and that money would be used to increase payments to hospitals and doctors who were.  If you aren't going to see your fair share of patients with little or no money, then you shouldn't get any government payment.  Most physicians and hospitals I know would gladly see poor patients, I suspect even for free, if they knew they were receiving fair price from those who could afford it.

My scheme has it all.  A market based universal access approach that would distribute physicians into critical access areas by nature of the market based pricing principles.  If you are the only cardiologist in a 300 mile radius, you have every incentive to move to critical shortage areas because you can charge more.  If you are one of 300 cardiologists in a 10 mile radius, you have every incentive to move as well because your competition will be fierce.  It allows the government to provide payment for the poorest of the poor while allowing those with more financial means to subsidize the government's low price points.  It forces patients to make good choices on price through transparency and competition, knowing they may very well get some of their deductible dollars back if they stay healthy, don't smoke, and exercise.  

My market based approach to universal access in our health care system.  A way to subsidize the care of inconvenient patients who can't pay from those who can.

A Market Solution To Controlling Health Care Costs

If you've been reading anything I have written, you won't be surprised that it involves putting skin in the game. That's exactly what Safeway did. And they're winning while the rest of America heads for bankruptcy. It's also a cornerstone concept of my proposed market based universal access for health care delivery that gives everyone skin in the game.

Today, Safeway has accomplished what Washington claims is the goal: The company's per-capita health-care expenses have remained flat, compared to the near 40% increase experienced by the rest of corporate America over the past four years. This has not been done by cutting care or shifting costs to employees. Nearly 80% of the 30,000 nonunion Safeway workers who take part in the program rate it good, very good, or excellent.

via AllFinancialMatters

An Inconvenient Patient

Tis better to just stop accepting insurance that pays you 13 cents on the dollar than it is to not make a patient your priority.  If you can't give your patient your all, you should not be seeing them at all.  Thanks to a reader for finding this story about an inconvenient patient.

MediCal cancelled me three times over the next year or so, and then denied me approval for an MRI, which my Doctor told me I needed before seeing a neurologist. Expecting the Doctor to call me when it was cancelled, I didn't find out for two months. When I asked what took so long to tell me, I was told (in front of my wife and kids) "You're a MediCal patient. I make thirteen cents on the dollar to see you. You just aren't one of my priorities". 

What's Your Strangest Insult From a Patient?

Mine is from a drug addict when I wouldn't give him his fix:

"I beat up people like you in high school"

What's yours?

Storms On The Horizon

Out of the Federal Reserve Bank of Dallas, comes this excellent presentation by its President and CEO, Richard Fisher about the fiscal disaster we currently find ourselves living in. Found  (Via Grand Rants)

Happy's  summary.  We are all screwed.  Every last one of us.  Unless a massive shift of policy is instituted today, we leave no future for ourselves or our children.  The entitlements we currently support are ponzi schemes a thousand times larger than Madoff and his thieves.

Tonight, I want to talk about a different matter. In keeping with Bill Martin’s advice, I have been scanning the horizon for danger signals even as we continue working to recover from the recent turmoil. In the distance, I see a frightful storm brewing in the form of untethered government debt. I choose the words—“frightful storm”—deliberately to avoid hyperbole. Unless we take steps to deal with it, the long-term fiscal situation of the federal government will be unimaginably more devastating to our economic prosperity than the subprime debacle and the recent debauching of credit markets that we are now working so hard to correct.

Stating the obvious, we are screwed.  But how is Social Security you ask?

Now, fast forward 70 or so years and ask this question: What is the mathematical predicament of Social Security today? Answer: The amount of money the Social Security system would need today to cover all unfunded liabilities from now on—what fiscal economists call the “infinite horizon discounted value” of what has already been promised recipients but has no funding mechanism currently in place—is $13.6 trillion, an amount slightly less than the annual gross domestic product of the United States.

Sounds like a lot of money, but that's the good news.  Read on:  

The good news is this Social Security shortfall might be manageable. While the issues regarding Social Security reform are complex, it is at least possible to imagine how Congress might find, within a $14 trillion economy, ways to wrestle with a $13 trillion unfunded liability. The bad news is that Social Security is the lesser of our entitlement worries. It is but the tip of the unfunded liability iceberg. The much bigger concern is Medicare, a program established in 1965, the same prosperous year that Bill Martin cautioned his Columbia University audience to be wary of complacency and storms on the horizon.

You should be afraid, very afraid of where we are heading.

Please sit tight while I walk you through the math of Medicare. As you may know, the program comes in three parts: Medicare Part A, which covers hospital stays; Medicare B, which covers doctor visits; and Medicare D, the drug benefit that went into effect just 29 months ago. The infinite-horizon present discounted value of the unfunded liability for Medicare A is $34.4 trillion. The unfunded liability of Medicare B is an additional $34 trillion. The shortfall for Medicare D adds another $17.2 trillion. The total? If you wanted to cover the unfunded liability of all three programs today, you would be stuck with an $85.6 trillion bill. That is more than six times as large as the bill for Social Security. It is more than six times the annual output of the entire U.S. economy.

And how much is that for you and me?

Let’s say you and I and Bruce Ericson and every U.S. citizen who is alive today decided to fully address this unfunded liability through lump-sum payments from our own pocketbooks, so that all of us and all future generations could be secure in the knowledge that we and they would receive promised benefits in perpetuity. How much would we have to pay if we split the tab? Again, the math is painful. With a total population of 304 million, from infants to the elderly, the per-person payment to the federal treasury would come to $330,000. This comes to $1.3 million per family of four—over 25 times the average household’s income.

What would you have to do to get make the unfunded mandates funded? 

1. Either increase federal tax revenue 68% starting today, and continue it forever.    Good luck with that.  When you tax something, anything, you will get less of it.  Nobody knows what tax rate could support that without destroying the economy in the process.
2. Or cut discretionary spending 97% (that includes defense, education, environment and everything else under the sun), forever.  

The issue isn't not enough taxes.  The issue is a government that can not say no to its constituents.  Now, I know some of you view Obama as your messiah, but I'm sure even he knows he can't generated 99 trillion dollars on the backs of the rich.   So the question is, does he have the guts to tell you no before it's too late? It takes a real leader to tell his followers no.  Right now, our leaders are promising everything and they will ultimately be able to deliver on nothing.

Is Percocet And Vicoden Going To Be Banned?

If the FDA follows the recommendations from a federal advisory board, the answer is yes. While I understand the logic, I fear for specialists everywhere who have never been trained to write for anything other.  I fear all their patients will go without pain medicine or get a "hospitalist consult for pain managment" 

FridaWrites, a patient with chronic pain gives her take on it all.