Rationing vs Rational Health Care

Health care.  Is it rationing vs rational.  One of the best essays I've read in a long time. I agree with it 100%.

Self Referral By Doctors in Health Care

What are your thoughts about self referral practices by doctors?  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.

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.

Should Doctors Negotiate Prices In Government Run Health Care?

Should physicians be able to negotiate prices in a government run health care plan?  With regards to a compromise by Blue Dog Democrats on setting the rates for paying doctors. 

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 hospitalist salary wins. You just may not like what your constituents are offering you. And you just might quit. How's that for unacceptable.

Dangers at County Fairs (Picture)

This is why county fairs can be dangerous. Look at that extension cord. Dang.

It Might Be Time For A Blog Break When

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.

(He's a fellow blogger)

Science Of Extrapolation (Cartoon)

Here's a cartoon representation (below) of 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 chiropractic care. 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?

A Cardiologist Does 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 doing a hospitalist preoperative evaluation   on healthy 34 year old pig farmers.  That's not the role of an internist. 

Scrubs or Prison Outfit: You Make the Call.

I'm not sure if this is a prisoner patient or a doctor. His scrubs could go either way.

What Is the Role Of The Internist?

What is an internist? And what is the role of the 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 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 bloodless 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. What is a hospitalist doing here?   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.

Doctor's Car Lot: Drive Your Lexus To Work Day At the Hospital

It must have been drive your Lexus to work day at Happy's hospital.

Six for Six.

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

What ist the greatest gift a physician can give to their patient? The right to die with dignity. Read on.

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 ethical issues. 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.

Home Garden Vegetables (Picture)

Just a boring picture of some of my home garden vegetables.  You're never going to get this minute back.

You Don't Know What You Don't Know

You don't know what you don't know.  And yes, there is research that says so.  From the Department of Psychology at Cornell comes this 1999 conclusion:

I'll  put it in simple terms:  Education =Ability

I'll put it 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 simpler than that, even for the uneducated.

How To Take My Synthroid or Levothyroxine: Morning? Night? Without Food? Same Time Every Day? Missed a Dose? Once a Week?

A reader asked the question on how to take their Synthroid or levothyroxine:

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. New 2010 research suggests you can take thyroid medication at night.   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 throughout 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.

Getting Care From A Doctor In the Top Tenth Percentile of Quality Or Top Tenth Percentile Of Income

From the New York Times

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.

Ignorance And Fear In Health Care

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.

Let's Just Make More Chemo

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.

Free Speech as a Right vs 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.

 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.

Will ObamaCare Euthanize Granny?

From the Washington Examiner comes this tidbit. An email circulating around the internet claiming ObamaCare will knock off granny.

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, super 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 ( Funny Joke)

The Lie Clock (joke of the day).

A man died and went to heaven. As he stood in front of St. Peter at the Pearly 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.

Does Obama Owe Physicians An Apology?

Does Obama owe physicians an apology?  EP cardiologist Dr Wes thinks so. And he points to Obama's remarks the other night:

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, bloodless 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.

Nuclear Isotope Shortage and How I Handled The Problem As A Hospitalist

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 nuclear isotope 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?

Cost Is the Enemy In Health Care

Cost is the enemy here. From the WSJ blog

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.

Standing On Short Flights If It Meant Cheaper Flights?

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.

Trillions of Dollars Missing From Federal Reserve Video?

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? 

Taco Bell Dog Dead At Age 15.

The Taco Bell dog died of a stroke. I don't think she smoked though.  RIP Gidget.

Smoking Lecture For Patients I Use As a Hospitalist Physician

I have a smoking lecture I use on all patients willing to listen.  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?

Common Physician Complaints

Two of the most common physician complaints are...

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.

How To Put Defense Lawyers Out Of Business

How do you put defense lawyers out of business?  The experience at one Michigan hospital is profound

Why?

What do patients want?  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 Bundled Care Is Upon Us

Here's a medical payment bundled care system that very well may change the way the business of health care is done in this country.  What is this payment model?  It's called Prometheus.  Bundled care is its game.

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 CPT Medical Coding 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. One can have hospitalist efficiency and profit too.  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.

Physicians Have A Moral Obligation Argument

The argument about whether physicians have a moral obligation 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.