Tuesday, March 29, 2005

New Jersey -- doing its best to make doctors leave the state

Un-fucking believable. In addition to the Medicare regulations, HIPAA paperwork, CME requirements, and malpractice CYA that they have to go through, now New Jersey physicians will have to go through mandated education about the unique needs of their patients from different cultural backgrounds. Where do you draw the line? How many different cultures will one be required to be proficient in? Will surgeons need to learn about the intricate medical beliefs of Australian Aboriginals? Or perhaps worry that they are not keeping up with the latest cultural shifts in Santeria?

In my community, there are a few Korean physicians. Guess what? Many Korean patients prefer to seen them. Great! That is how things are supposed to work. If I (can't help it, I'm one of those satanic white males) come off as "culturally insensitive," I won't get to see certain patients, for the same reason that I wouldn't see many women if I am overtly sexist. That is what is known as the FREE MARKET. It is MY JOB to make sure that I care for my patients in the best manner that I can, regardless of their ethnicity, religion, background, etc. This type of feel-good mumbo jumbo has the stamp of the AMA all over it, and it is truly ridiculous. Those that promote these laws make a fatuous argument about "diversity," without understanding the important issues of free choice and personal responsibility.

Is Your Doctor "Tiered" for Payment?

Gone are the days when HMOs could rationally say that they would be able to find ways to keep costs down by providing "economies of scale" and "ensuring cost efficient practices." It is pretty evident that the way that premium costs were held down over the past 10-15 years is that the HMOs forced physicians and hospitals to accept lower reimbursement for their services. They did this so well that their profits soared, leading to overpaid CEOs and unrealistic Wall Street expectations for future growth and earnings.

Let's just say that the bottom of the barrel has been reached. Hospital operating margins are razor thin, and physicians are unwilling to accept further decreases in payment. Presently, much of the insurance companies' profits come from denial and delay of payment, making money on the "float." In my practice, it has become routine that payment for even preauthorized procedures are subsequently denied, with payment significantly delayed; protests are met with cries of "ERISA," which legally prevents us from pursuing legal action.

Now we see the latest attempt to squeeze physicians further, "tiered" payment (emphasis is mine):

Some plans, like Premera and Blue Cross of California, are comparing doctors' relative cost-effectiveness. Others, including Aetna and PacifiCare, are also factoring in clinical quality. But even when they do that, cost remains king.

PacifiCare, for example, culls the most efficient physicians for its Value Network before it evaluates their clinical performance. "We need to be able to offer it on a discount basis compared to a standard network," explains FP Sam Ho, PacifiCare's chief medical officer. "If you're not going to be cost efficient, there won't be much attraction for this product."

Ho observes that some doctors who score high on quality are less cost-efficient than other physicians. "If consumers want those providers, they can select them in the standard tier, but they have to pay more. For instance, they have to pay 30 percent coinsurance instead of 10 percent. Or, in the standard network, maybe they'll have to pay 10 to 15 percent more in premiums than they would in the Value Network.

So, if your insurance company offers you a lower co-payment to see Dr. X versus Dr. Y, is that a good deal for you? Chances are, you'll never know. As Medpundit aptly points out,
And how do they decide who rates for the favored program? Not by reviewing their charts or patient outcomes, but by looking at the money the insurance company spent paying claims.

Across the country, millions of dollars are being spent by hospital systems, physician groups, medical schools, etc. to identify and promote "best practices;" this basically means that we are constantly looking for ways to improve patient care. Generally speaking, most (sane) people would agree that the best way to care for patients is to get them into the hands of the most qualified physician to handle their particular problem. It is my contention that patient care costs rise (rather precipitously) when this basic tenet of care is circumvented, often with the purported goal of "cost savings."

I would also like to point out that when discussing a pancreatectomy or laparoscopic splenectomy with a patient and his/her family, I have never been asked if I am the "discount" physician.

Saturday, March 19, 2005

"Bargaining" with HMOs

It has long been a tenet of modern medicine that physicians will simply have to accept ever declining reimbursement. For me, the bottom has been reached. While my group has occasionally cancelled or turned down bad contracts, in general the insurers came back with a more acceptable offer.
We are now faced with a new contract from UnitedHealth, which contains language so odious that we will be terminating 15% of our business to avoid signing. What, besides poor pay, can be so difficult to accept? Basically, the contract states that United may, at any time, change our reimbursement, and we are unable to then drop out of the contract. So, the day after the contract is signed, they are able to drastically alter the pay structure, and we are obligated to honor the contract for the next 12 months.
I wonder if Bill McGuire, their CEO, would sign such a deal. After all, he made only a paltry $10 million in salary last year (but look at the stock options exercised). I could care less if Dr. McGuire is successful; I would just like the ability to openly share this information with my fellow physicians in town without the fear of antitrust reprisals from the feds.

Thursday, March 17, 2005

Every Physician Should Read...

This article by Father Robert Johansen, probably the most well-reasoned, and damning, discussion of the planned starvation of Terri Schiavo. There is nothing I can add, except my strongest recommendations to read this important expose. This is a bastardization of the idea of "death with dignity." It is, quite simply, murder sanctioned by the state.

As Hugh Hewitt has aptly stated, if the swift applcation of a lethal injection in an execution is felt by the left to be cruel and unusual punishment, what words are left that describe forced starvation?

The FEC and The Blogosphere

OK, so I'm a newbie, a neophyte, a babe in the woods...I'm very green at this whole blogging thing. One thing I do know, however, is that there is absolutely no justification for the FEC to regulate blogs. Period. The only folks interested in controlling the blogosphere are the same ones who feel that freedom of speech only applies to incumbent politicians. So, let me follow Patterico's lead and state:

If the FEC makes rules that limit my First Amendment right to express my opinion on core political issues, I will not obey those rules.

And while I'm angrier than a 2cm zit on a teenager's face, let me state that Newsweek's Steven Levy has the kind of insight that God normally intended for a mollusk. He asks the unbelievably inane question "Does the blogosphere have a diversity problem?" Guess what? The blogosphere is populated by people, interested in an unbelievably wide range of topics, many of whom are totally anonymous. So, as Jeff Jarvis says:
"I'm white and male. Not much I can do about it. Not much I want to do about it. I'm sure as hell not going to apologize for it. I'm white. I'm male. I blog. You got a problem with that? Tough."

Anyone can blog; I'm certainly ample proof of this. That means any man, woman, boy, girl, Catholic, Jew, Muslim, atheist, Hispano/Anglo/Sino-American can blog. There is an inherent impossibility of bias against a person's race/creed/ethnicity in the blogosphere.....because bloggers can only offer their ideas and thoughts for everyone else to critique. I love Michelle Malkin's opinions, and can't stand Wonkette's; they both happen to be women. Does that somehow make me 1/2 sexist?

Why is it that the same yahoos that think it is so important to have "diversity" are the same ones hell-bent on controlling the free expression of so many truly diverse people in the blogosphere?

Tuesday, March 15, 2005

Pay for Performance

Medicare has a pilot program that sounds intriguing, at least on first glance. Basically, it is a plan that is designed to reward good patient outcomes. To put it simplistically, if a physician provides good care for his/her patients, and those patients have good outcomes, that behavior is rewarded. On the surface, that sounds fairly reasonable, and certainly looks as if it can be applied to many facets of health care, such as diabetic care, cardiovascular surgery, hip replacement, etc. Those arenas tend to have fairly readily defined parameters for care and outcomes.

Unfortunately, the delivery of medical care is not something that can be easily rated, as there are innumerable complex issues that tend to confound the actuarial analysis of data. The data itself is hardly easily defined; who gets to decide what is clinically relevant in the care of a patient? For example, is it a "complication" of an abdominal operation for a patient to have an (expected) postoperative ileus? If a patient is reluctant to follow a physician's recommendations, will it reflect negatively on his "grade?"

As a surgeon who cares for often very sick patients on a routine basis, I am hopeful that there can be some system devised that recognizes the difficulties encountered when multiple medical (as well as social) issues complicate the ultimate outcome of individual patients. I am skeptical, however, that such a system will be fair in rating those of us who do not turn away the very sick, the elderly, and the complex patient. I worry that it will encourage physicians to avoid those patients like the plague, lest they become a "pox" on their Medicare-approved rating. In my field, we'd be left with legions of general surgeons "qualified" and willing to take out gallbladders and fix hernias in the under 40 age bracket, and no one left to care for the 86-year-old with an obstructing colon cancer.

Medpundit has a few well reasoned thoughts about this as well from a primary care perspective. She asks perhaps one of the most salient questions about this initiative:

In the long-run, what will happen to those patients who can't achieve numerical perfection? Or who can't quit smoking? Or who just can't bring themselves to have a colonoscopy? Will doctors refuse to take them on as patients, knowing they won't get paid for taking care of them? It would be a very mercenary thing to do, but it's likely to happen. A doctor who can't pay his bills is a doctor who can't practice medicine.

Saturday, March 12, 2005


"The Gross Clinic"


"The Gross Clinic" and "The Agnew Clinic". You can tell Eakins spent some serious time around the medical school --- look at the sleeping students in the background of "The Agnew Clinic."

Today's History Lesson

On (trauma) call today, stuck in the hospital......so I thought I'd indulge in a little history lesson. This is sort of like therapy for me, knowing that many of the smartest docs in history failed, and did so frequently.

One of the most famous surgeons in all of medicine was Joseph Lister, well known to medical students as the father of antiseptic technique. Prior to his time, the "four horsemen of infection" overran surgical wards -- septicemia, pyemia with disseminated abscesses, "hospital" gangrene, and erysipelas. Things were so bad that Sir James Simpson was led to state

"The man laid on the operating table in one of our surgical hospitals is exposed to more chance of death than the English soldier on the field of Waterloo."

The results that Lister was able to achieve were, quite frankly, revolutionary in their importance to the care of the surgical patient. They were not, however, universally recognized or adopted at first. There is no better illustration of this than the differences that can be seen in the two most famous American medical paintings ever produced, Thomas Eakins' "The Gross Clinic" and "The Agnew Clinic," which are located above this post.

Dr. Samuel Gross, the senior statesman of American surgery, was an outspoken opponent of Listerism, and refused to employ antiseptic principles. Hence the 1875 "Gross Clinic" painting accurately reflect the operation being performed with a total lack of antisepsis -- Gross wears the traditional blood-caked black frock, there are no drapes, etc......9 years after the publication of Lister's landmark papers.

Fast forward 13 years to the 1889 "Agnew Clinic" painting. David Hayes Agnew and all of his assistants are dressed in clean white coats and the patient is clearly draped in a much more antiseptic fashion. What a difference a few years, and a little hubris makes.

Haloscan commenting and trackback have been added to this blog.

Thursday, March 10, 2005

Mistaken for a Panacea

Computerized physician order entry (along with its running buddy, the elusive electronic medical record) has been the holy grail for those medical public policymakers who believe that there is a relatively simple solution to medical errors in hospitals. Unfortunately, the perfect solution has yet to be found. As this new article in JAMA illustrates, the process of implementing such a system is fraught with complexities that were previously unimaginable.

Industry leaders in other fields have rightly identified medical errors as a problem, but have yet to understand that the solutions generated by those highly skilled IT folks from the business world rarely work unless there is a large amount of input from those who actually care for patients. A perfectly workable solution in the eyes of a computer programmer can seem like a maddeningly obtuse obstacle to a physician or nurse working at 2AM. As well, while other industries can take a "trial and error" approach to making their systems safer, those "errors" in this instance translate into "patients."

Other thoughts about this can be found at GruntDoc and Surgical Diversions. My personal,longstanding conviction is that the dreaded Microsoft corporation is the only company that has the scope, understanding, and practical knowledge of how to "make software work for everyone" to achieve the desired result. I'd love to see them hire a few dozen practicing physicians and nurses as consultants and collaborators and get busy. Unfortunately, there is that pesky monopoly problem that would have to be avoided......

Fact or Agenda-Driven Fiction?

There has been no shortage of coverage over the past few months about the study that purports the over half of the bankruptcies in the US are due to medical bills. The Harvard report unfortunately does not take into account the actual facts that the study actually revealed. Indeed, there are many people who are forced to go through banckruptcy due to medical bills, but the numbers that the study itself produced have to be significantly massaged in order to meet the greater than 50% claim. A dispassionate, well-informed National Review Online article briefly sums up the information and delineates how its flawed conclusions were reached. In particular, there is an imaginative use of the term "medical cause" of bankruptcy, which is taken to include such diverse medical issues as compulsive gambling, drug or alcohol addiction, or the birth or adoption of a child.

Why would such a flawed study be published, much less be lauded in the press as such an important milestone? The rather simple, and regrettable, answer, is because it is inherently biased towards the establishment of a universal (i.e., taxpayer funded, cradle-to-the-grave) health care system. This inherent bias is not revealed by the main author of the article, but her views on the subject have been made quite clear elswhere. Whether or not one believes in a universal health care system is moot; it is important to get factual, unbiased evaluation of the data before making major changes in health care policy.

Tuesday, March 08, 2005

This article perfectly illustrates why "middle America" no longer listens to pleas for "academic freedom" or diatribes about the absolute need for tenure at America's universities. While Ward "trigger finger" Churchill gets lionized by the faculty at the University of Colorado, someone who actually does his job --- teach his course while teaching students to think --- is quietly dismissed. I think it's great that CU President Betsy Hoffman is leaving; it would be wishful thinking to hope that portends a shift in attitude on the part of the ultra-left faculty, however.

Saturday, March 05, 2005

A Case of Mapractice?

The Seattle Times: Health: Oregon man wakes up after assisted-suicide attemptThe practice of physician assisted suicide gets scarcely noted in today's press. Pity. We (doctors) are here to help, to heal, to hold, to assist...but not to kill. Perhaps what is most telling about this unfortunate man's experience is written in the last paragraph.

Medical Malpractice Morass

Asymmetrical Information: Arguments that don't quite make the case you think
For those who want to get gently pushed into the medical malpractice arguement arena, this is a good place to start....and many of the comments are worthwhile as well. Thrown in with this are a healthy dose of "work hour restriction" questions. These issues will begin playing a larger role in the debate about medical care in this country over the next few years; we cannot continue to cut reimbursement to physicians while drastically increasing their malpractice insurance premiums and mandating decreased work hours (and thereby decreasing reimbursement further). There is also the largely underreported gender issue in medicine --- at the risk of being strung up like Larry Summers, half of the physicians we are now training are not expectede to work the same hours or have the same career span as their male counterparts.