Category Archives: medicine

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Healthcare Reform Update

The New England Journal of Medicine, the premier Journal in all of medicine, has had its lead articles for months focus on health care reform.  The last issue finally had 1 article with the fiscally conservative opinion; the rest have been extremely bias, unfortunately.

I have learned that Canada’s system for many years after reform continued to climb in costs!  Massachusetts health care system that many legislators view as the model and goal to strive for has been found to cost a typical family MORE money and higher premiums!

Finally there is a recent article that points out that 31% of the U.S. population believes that they will be worse off than they are now.

Any thoughts?

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Love Binds Doctors to their Patients in a Unique Way

Truth in the Cathedral of Medicine

Leap, Edwin MD

Dr. Leap is a member of Blue Ridge Emergency Physicians, an emergency physician at Oconee Memorial Hospital in Seneca, SC, and an op-ed columnist for the Greenville News. He welcomes comments about his observations, and readers may write to him at emn@lww.com and visit his web site and blog at www.edwinleap.com.

When this is published, we could be on our way to a new health care system. I don’t know what that will entail. Few in the government really want my opinion. That’s the way it is; we have limited power. Or do we?

Last night at work, I diagnosed a man near my age with new onset diabetes and osteomyelitis of the toe. He was terrified, and fear radiated from his face. He was afraid of diabetes, of neuropathy, of amputation.

We talked a while as I dealt with his blood glucose, then admitted him to the hospital for a surgeon to evaluate his foot and a hospitalist to control his diabetes. He thanked me for smiling and being kind. We shook hands and laughed before he went upstairs into his diabetic future. He felt better. He felt that someone cared for his situation.

Reform or not, the one thing we can do as physicians is just that. We can be competent and compassionate. We can smile and touch. We can do the right thing as long as government lets us. (Pay attention to that thought: as long as they let us. Store it away, and watch the future unfold.)

I have been told by some that government-run health care would be better than industry-driven health care. I have been told the opposite as well. Each side makes the argument that it will have greater accountability to the sick. Advocates for government suggest that we as citizens can hold them to more rigid standards, can get what we want and need more effectively through the legislative process. Those for the market believe that profit will always do a better job of driving customer satisfaction, efficiency, and lower costs, that profit and shareholder interests will make the market a better choice.

I have an idea about that. The only direct accountability any patient can ultimately exercise is between caregiver and patient. You can argue on the phone for weeks, and never speak to the right person at an insurance company. They can delay and evade for months. You can call your favorite government functionary who works behind a shield of anonymity and distance, guarded by layers of voice-prompts on telephones. None of them is accountable the way we providers are.

And so, we have power. We can do what I did with my diabetic friend. We can touch and smile. We can care. We can do the right thing as much as possible. We can show compassion, live compassion, feel compassion. We entered medicine because we genuinely cared about the sick, the dying, and the broken. Our best hope for the future of medicine is to continue to do the same, or if lost, to rediscover what was driven from our hearts.

Our proximity to the sick is an advantage no one else possesses, and in truth, that no one else desires. Our love for them is the most powerful weapon we have as we try to reform.

I don’t know what the future holds. I hope it holds continued jobs, continued freedom and choice, continued competence in medicine. I hope it involves amazing innovations and improvements in quality of life.

But whatever it holds, good or bad, I do know the way to safeguard our place in the process as physicians, nurses, and other health care providers. The solution for caregivers is, ironically, to give care! If we give care, if we give love and concern, if we give of ourselves to those suffering, we will have far more power than any government functionary or insurance company voice on the phone.

We may have our payments cut, our influence squashed, our opinions silenced. But our compassion will continue to connect us, our love will continue to rebuild the broken and to speak with a thunder no government or corporation can match.

Maybe, in the end, we can reassume control of health care. And why not? We know it better than anyone else; we know the sick better than anyone. We touch them, treat them, listen to them, and even see them leave this life. Those are powerful qualifications for leadership.

But we’ll never have control, ever again, if we give up the one velvet weapon we have, which is love for those charged to our care. For faith, hope and love abide these three, but the greatest of these is love. And it’s never more true than in the cathedral of medicine.

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Emotions

“Emotions are the window to reality.”  Really? I have not bought into that.  Why? Probably because I was raised to be out of touch with my emotions.  I strive at being non-emotive.   But it turns out that emotions and their physiological effects play a key part in our decision making.

Why do police departments generally do not allow their officers to participate in high speed chases?  What is the cause of most medical errors? Answer: Emotions.  Really? Yes.

In Malcolm Gladwell’s book Blink,  Gladwell points out that there is a physiological response to stress/fear/anger/ie our emotions.  One of the findings reported by a police officer who has studied police shooting incidents has found that when we are stressed and our heart rate goes about 145 beats per minute we start to lose our ability to reason, think clearly, etc.  There is a sweet spot to stress when our heart rate is between 110-145 our body responds by making our ability to think clearly sharper in this heart rate range.  Some police departments have banned high speed car chases for this very reason.  They have found that the police in a high speed chase are so stressed that they will often respond by being overly aggressive at the time of arrest.

Dr. Groopman in How Doctors Think points out that most medical errors are related to our emotions…

“But what I and my colleagues rarely recognized, and what physicians still rarely discussed as medical students, interns, residents, and indeed throughout their professional lives, is how other emotions influence a doctor’s perceptions and judgments, his actions and reactions. I long believed that the errors we made in medicine were largely technical ones—prescribing the wrong dose of a drug, transfusing a unit of blood matched for another person, mislabeling an x-ray of an arm as “right” instead of “left.” But as a growing body of research shows, technical errors account for only a small fraction of our incorrect diagnoses and treatments. Most errors are mistakes in thinking. And part of what causes these cognitive errors is our inner feelings, feelings we do not readily admit to and often don’t even recognize.”

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Anxiety, the Worried Well, and Healthcare Reform

A friend just sent me this article from the Pittsburgh Post-Gazette.  It is insightful, true, funny, but a little harsh at times. The take home message is important: do not be anxious….

Sunday, October 11, 2009

Pittsburgh Post-Gazette

Emergency departments are distilleries that boil complex blends of trauma, stress and emotion down to the essence of immediacy: What needs to be done, right now, to fix the problem. Working the past 20 years in such environments has shown me with great clarity what is wrong (and right) with our nation’s medical system.

It’s obvious to me that despite all the furor and rancor, what is being debated in Washington currently is not health-care reform. It’s only health-care insurance reform. It addresses the undeniably important issues of who is going to pay and how, but completely misses the point of why.

Health care costs too much in our country because we deliver too much health care. We deliver too much because we demand too much. And we demand it for all the wrong reasons. We’re turning into a nation of anxious wimps.

I still love my job; very few things are as emotionally rewarding as relieving true pain and suffering, sharing compassionate care and actually saving lives. Illness and injury will always require the best efforts our medical system can provide. But emergency departments nationwide are being overwhelmed by the non-emergent, and doctors in general are asked to treat what doesn’t need treatment.

In a single night I had patients come in to our emergency department, most brought by ambulance, for the following complaints: I smoked marijuana and got dizzy; I got stung by a bee and it hurts; I got drunk and have a hangover; I sat out in the sun and got sunburn; I ate Mexican food and threw up; I picked my nose and it bled, but now it stopped; I just had sex and want to know if I’m pregnant.

Since all my colleagues and I have worked our shifts while suffering from worse symptoms than these (well, not the marijuana, I hope), we have understandably lost some of our natural empathy for such patients. When working with a cold, flu or headache, I often feel I am like one of those cute little animal signs in amusement parks that say “you must be taller than me to ride this ride” only mine should read “you must be sicker than me to come to our emergency department.” You’d be surprised how many patients wouldn’t qualify.

At a time when we have an unprecedented obsession with health (Dr. Oz, “The Doctors,” Oprah and a host of daytime talk shows make the smallest issues seem like apocalyptic pandemics) we have substandard national wellness. This is largely because the media focuses on the exotic and the sensational and ignores the mundane.

Our society has warped our perception of true risk. We are taught to fear vaccinations, mold, shark attacks, airplanes and breast implants when we really should worry about smoking, drug abuse, obesity, cars and basic hygiene. If you go by pharmaceutical advertisement budgets, our most critical health needs are to have sex and fall asleep.

Somehow we have developed an expectation that our health should always be perfect, and if it isn’t, there should be a pill to fix it. With every ache and sniffle we run to the doctor or purchase useless quackery such as the dietary supplement Airborne or homeopathic cures (to the tune of tens of billions of dollars a year). We demand unnecessary diagnostic testing, narcotics for bruises and sprains, antibiotics for our viruses (which do absolutely no good). And due to time constraints on physicians, fear of lawsuits and the pressure to keep patients satisfied, we usually get them.

Yet the great secret of medicine is that almost everything we see will get better (or worse) no matter how we treat it. Usually better.

The human body is exquisitely talented at healing. If bodies didn’t heal by themselves, we’d be up the creek. Even in an intensive care unit, with our most advanced techniques applied, all we’re really doing is optimizing the conditions under which natural healing can occur. We give oxygen and fluids in the right proportions, raise or lower the blood pressure as needed and allow the natural healing mechanisms time to do their work. It’s as if you could put your car in the service garage, make sure you give it plenty of gas, oil and brake fluid and that transmission should fix itself in no time.

The bottom line is that most conditions are self-limited. This doesn’t mesh well with our immediate-gratification, instant-action society. But usually that bronchitis or back ache or poison ivy or stomach flu just needs time to get better. Take two aspirin and call me in the morning wasn’t your doctor being lazy in the middle of the night; it was sound medical practice. As a wise pediatrician colleague of mine once told me, “Our best medicines are Tincture of Time and Elixir of Neglect.” Taking drugs for things that go away on their own is rarely helpful and often harmful.

We’ve become a nation of hypochondriacs. Every sneeze is swine flu, every headache a tumor. And at great expense, we deliver fantastically prompt, thorough and largely unnecessary care.

There is tremendous financial pressure on physicians to keep patients happy.
But unlike business, in medicine the customer isn’t always right. Sometimes a doctor needs to show tough love and deny patients the quick fix.

A good physician needs to have the guts to stand up to people and tell them that their baby gets ear infections because they smoke cigarettes. That it’s time to admit they are alcoholics. That they need to suck it up and deal with discomfort because narcotics will just make everything worse. That what’s really wrong with them is that they are just too damned fat. Unfortunately, this type of advice rarely leads to high patient satisfaction scores.

Modern medicine is a blessing which improves all our lives. But until we start educating the general populace about what really affects health and what a doctor is capable (and more importantly, incapable) of fixing, we will continue to waste a large portion of our health-care dollar on treatments which just don’t make any difference.

Michael Werdmann, MD

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Flu Update: More Stats

CDC announced that up to 6 million swine flu cases in last few months! So now looking at the total of deaths worldwide 6051, we are looking at a mortality rate of .001%.  Unfortunately the people that do get sick and who are at risk of serious illness are kids whereas the regular seasonal flu tends to effect babies and old people.  (original article from CDC)

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Head Injury in Kids

This is a VERY common concern that I see at work.  “My kid has fallen and hit their head.”

This article clarifies that the VAST majority of head injuries in kids are nothing to worry about and do not need imaging.

Kids under 2:  If they have “normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents”, then they are at very low risk, and they do NOT need imaging.

Kids over 2:  If they have “normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache”, then they are at very low risk, and they do NOT need imaging.

They obtained a total of  14,969 CT scans and only 0.1% needed neurosurgical intervention.

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Flu Update: 1 in 5 Kids had H1N1 (swine) flu this month

An article today points out that it is estimated that 1 in 5 kids in the U.S. contracted swine flu in the month of October, 2009. Now looking at the demographics of the U.S., it is estimated that there are 60 million kids ages 0-14 in the U.S. in 2009.  This means that approximately 1.2 million kids had the H1N1 flu this month.  The total deaths from the H1N1 flu in the U.S. is estimated at 1,164. Therefore the mortality rate in kids in the U.S. can be estimated to be far less than 1% (.00097).

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Flu Update: The H1N1 (Swine Flu) is upon us!

I was stopped by a friend this morning who was concerned about the swine flu because he watched a 60 Minutes special last night about a teenager who died of the swine flu.  The special went into detail about this poor teenager’s suffering and death (or so I was told–I didn’t see the special).

It is time to STOP the presses!  The press/media is making people panic.

The facts:

  • If you have fever, cough, body aches, and/or headache, you have the flu–it is widespread and epidemic
  • 55,781 confirmed cases in U.S. & 1,081 deaths=mortality rate=1.9% NOW these stats are WAY off because those are the confirmed cases meaning cases that have been tested.  There are probably double that many of cases that were tested and were false negatives (had the flu but test was wrong–30-50% of the time!).  There are probably 10 times (at a minimum) more cases of the flu so probable cases of the flu in U.S. likely 500,000 or more so that means the mortality rate is far less than 1%.
  • The problem–those who are dieing are young and healthy.  Regular flu kills 30,000 people per year but they are very old or very young people.  New pandemic flu strains attack the people in their prime.  This is what drives the media to report on the deaths.  We HAVE TO keep it in perspective.
  • The vaccine scare–The H1N1 vaccine was created in the SAME process that the regular seasonal flu vaccine is (they would have mixed the seasonal flu vaccine and the H1N1 vaccine in the SAME shot if they had had the time).  The vaccine is safe (as safe as the regular seasonal flu vaccine.
  • tamiflu–NOT recommended unless person with the flu is immunocompromised otherwise tamiflu is NOT recommended (and it is NOT without it’s own side effects)
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Wear a HELMET!

My ENTIRE family wears helmets when they ride bikes, skateboard, razor, etc.  I started wearing a helmet after I saw an 11 year old girl die before my eyes when I was in training.  She was roller blading on her street and a car at low speed hit her.  She tore one of the main arteries in her brain, and you could see the blood gushing out of her nose–it was very graphic and memorable.  Wear a HELMET!

I am always amazed at how few kids wear helmets in my neighborhood even when driving around in the motorized scooters.  Wear a HELMET!

I just received an email about a kid who was not wearing a helmet and fell off his skateboard and had multiple skull fractures and a severe concussion.  This is what his mom said in her email:  “If there is a lesson as a parent that Mark and I have taken, it is to hug your child every day and look at them for the perfect creatures that they are, and as a true gift from God.  Don’t sweat the small stuff, because life can change in an instant!  And, . . . to make them WEAR A HELMET, even if they think they are too cool.  That includes us as parents, as I will be purchasing myself one before our next bike ride.  So to my friend Patricia, who I always see riding with her helmet on and giggle, I will soon be in your club!”

Wear a HELMET!

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Francis Collins, Part 1 & ‘finding waldo’

Have you ever played the book game ‘finding waldo’? I thought I would share this brief article and see if anyone wants to post a comment sharing with us what they find ironic/problematic with this article that was the lead article in medicine’s premier journal-The New England Journal of Medicine. I will share what I found in a follow up post.

Opportunities and Challenges for the NIH — An Interview with Francis Collins
Robert Steinbrook, M.D.
Francis Collins, the physician and geneticist who was sworn in as the 16th director of the National Institutes of Health (NIH) in August 2009, anticipates scientific opportunities and budgetary challenges. Although the NIH received $10.4 billion in new funding under the American Recovery and ReinvestmentAct, the money must be spent by September 2010 and the institutes’budget has otherwise been relatively flat since 2003 (see graph).1 Fiscal year 2011 begins on October 1, 2010, and prospects are uncertain.

Collins, 59, has led the Human Genome Project and directed the National Human Genome Research Institute at NIH; his laboratory has identified many important genes. He also established the BioLogos Foundation, which addresses the interface between science and faith, and wrote a best-selling 2006 book, The Language of God: A Scientist Presents Evidence for Belief. Some observers expressed concern that his personal religious beliefs would affect his judgments as NIH director.2 When he became director, Collins resigned from the foundation, ended his involvement in public discussions about science and faith, and provided reassurances that his agenda for the institutes is scientific, not religious.
(vol 361:1321-1323 October 1, 2009)

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Healthcare Reform: Finally a concise & accurate article

I have been reading all the articles about the healthcare issue in the New England Journal of Medicine–medicines premier journal.

I have been disappointed by the wordiness, political biases, and inaccuracies of the articles in the NEJM.  I have finally come across a concise & accurate article:

Health Care Reform and Clinical Culture

It is a tired and cynical cadre of physicians who will implement health care reforms. Yet few published perspectives include the view from the factory floor. The usual platitudes about changing financial incentives, increasing efficiency, and delivering high-quality care sound naïve to clinicians who deal with the imperfections of human nature and the messy effects of illness on patients. Doctors are already, by training, sophisticateddecision-making machines, capable of achieving extreme efficiency through the use of heuristics and experience.The main problems that clinicians face in achieving efficiency and reducing costs are, first, a perceived need for certainty in diagnosis and treatment — a need driven by secular expectations and malpractice concerns; second, gross inefficiency created by obligatory documentation to satisfy billing requirements that have little value for clinical care; and third, restrictions on the use of clinical judgment that could avoid excessive testing. None of these problems, whose solutions would save money and time, have been incorporated into the national discussion about reform.

One change that would augment the role of clinical judgment would be for the health care system to resist the temptation to require adoption of often-elusive “best practices.” Therehas been an assumption by analysts that published clinical trials provide a sound guide for therapy, but all reputable studies report odds, hazard ratios, and effect sizes, almost all ofwhich are small or modest. Absolutes are discordant with the realities of sickness and health. There may be guidelines and measurable outcomes for mundane problems, but for the vast majority of daily doctor’s visits and hospital decisions, incremental or recursive approaches to diagnosis and treatment are more effective and efficient.

A second reform should be to limit malpractice awards so as to reduce physicians’ fear of lawsuits. Regardless of the arguments of defenders of open-ended malpractice payments, this insidious concern is a major driver of overtesting and overconsulting.

A third key reform would be to eliminate the time sink of the comprehensive exam and its lengthy documentation required by Medicare — a requirement that is likely to be adopted or exaggerated in any new codified system. Immaterial information is already cluttering the electronic medical record. My survey of neurology notes, which I presume would be among the most thoughtful in medicine, shows that less than one fifth of the average note is taken up with analysis and discussion of the patient’s problem; the remainder is part of the “waste” in modern medical care.

Fourth, payment codes should be reduced to “simple” and “complex” — or at least the numerous billing levels and codes should be conflated, and payment should be based on diagnosis and time expended. Physicians should also be paid for their expertise.

Health care reform can redress slowly accrued and detrimental cultural changes, particularly the loss of reliance on clinical judgment. It would be a missed opportunity if practicing physicians (as contrasted to their representative bodies and societies) were excluded from the center of the conversation. The efficient use of the professional workforce will be more powerful than rules.
Allan H. Ropper, M.D.
Brigham and Women’s Hospital
Boston, MA

This article (10.1056/NEJMopv0907607) was published on August 26, 2009, at NEJM.org.

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Patient Satisfaction Linked to Expectations

This article in the September 2009 Annals of Emergency Medicine: Patient Satisfaction as a function of Emergency Department Previsit Expectations points out, once again, the importance of interpersonal skills often can be more important than what you know and what skills you have as a physician.  I am confident this applies to most occupations.

Books such as How to Win Friends and Influence People can help us to be better husbands, friends, parents, and professionals by focusing on interpersonal skills.  I strongly recommend this book.

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Medical Myth #6 (example #4): Placebo’s don’t work

The power of the placebo is so incredible and interesting that I have shared many examples from this thought provoking book (Enjoy example #4):
Hippocrates’ Shadow: Secrets from the House of Medicine (David Newman)

“Moerman describes a study in which placebo injections for pain are given to two sets of patients under nearly identical circumstances. In the first, the physician is told that theres no chance that a real narcotic medication will be given. In the second, the physician is told that theres a chance that the patient will receive a narcotic. In both cases the patient receives a placebo, but the placebo is far more effective in relieving pain in the second case, when the physician believes that a narcotic may be in the injection. While the impact is very different in these cases, the only difference is in the physicians beliefs.”

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Medical Myth #6 (Example #5): Placebo’s don’t work

This is the 5th and final example of the placebo effect from Hippocrates’ Shadow: Secrets from the House of Medicine (David Newman):

“In 1961 Henry Beecher, a distinguished Harvard professor and researcher of the placebo effect, published a paper comparing sham heart surgeries in two groups of patients from two different studies (the paper discussed only those who had received shams, not the real surgeries).* Using observations of interactions between the physicians and patients Beecher described the surgeons as enthusiasts or skeptics based on their attitude toward the procedure and toward the patients having the procedure. Patients of the enthusiast surgeons achieved nearly four times more complete relief of their chest pain and heart problems than patients of the skeptics….

…The healing is in the psychosocial and biologic contextthe contact, the ceremony, the bond between doctor and patient. The healing is not in the pill or the scalpel any more than the strength to run faster was in the sneaker, or the taste was in the color of the can….

…Medical education, taught primarily by physicians, is a reflection of medical culture. Currently, we dont routinely teach the meaning response. In heart disease and major depression, to name only two, estimations of the effect of placebo pills have shown that theyre proportionally more effective than most real medications.”

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Medical Myth #6 (example #3): Placebo’s don’t work

Here is yet another example of the power of the placebo from Hippocrates’ Shadow: Secrets from the House of Medicine (David Newman)

“…Just five months after Dr. Freeds group published their work, a group in Vancouver, Canada, published a study…using a brain imaging technique called positron emission tomography scans, or PET scans, the researchers recorded the production of dopamine from the diseased areas of the brains of Parkinsons patients. While this had been done before, the researchers performed the images on an unusual group: patients from the active treatment and placebo groups of a trial being done to test a new drug for Parkinsons at their medical center. The PET scans showed that patients receiving placebos had visibly and measurably increased dopamine output from the diseased cells. The PET scans had allowed researchers for the first time to see the placebo effect….

Skeptics have argued that these studies dont provide evidence of a true physiologic placebo effect because pain, or even nausea, can be a subjective measurement. But dopamine output in the brain, and endorphins, are not subjective. Physical healing is also not subjective. Just as more pain reduction is seen with two placebo pills than with one, ulcers seen by endoscopy in the lining of the stomach or intestine heal more quickly when a patient is given two placebo pills rather than one. Real medicine reduces high blood pressure, but an inert pill does so as well, albeit somewhat less effectively. Real medications for asthma dilate the lung passages, making it easier to breathe; but if you tell an asthma patient that hes going to receive a medication that will dilate his lung passages, and then give him an inhaled placebo, his lung passages dilate. The patterns of placebo response are virtually identical to the patterns seen when using an effective pill.”

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Healthcare Debate: Malpractice Reform

3rd and final article from Emergency Physicians Monthly…saved the best for last.  This is the single most important issue in all of the physicians minds that I have spoken with, but of course, no one in politics has addressed it. I wonder why? Hmmm…

Just A Spoonful of Reform Print E-mail
by Greg Henry, MD

These are clearly the times that try men’s souls, or at least their patience. As health care reform is being contemplated throughout the country, there are more and more chances that we’ll get it wrong as opposed to getting it right. However, disagreements aside, emergency physicians need to come together and decide what goals we will put forward. We need to stop wasting time asking whose name is on the bill and start asking if the policies will meet the long-term goals of our specialty. There are many policy areas where emergency physicians need to get involved, from services rendered to workforce issue, but let’s begin with the medical-legal structure since we are most likely to get some unanimity in this area. I’ll give some ideas that I think are straightforward and could be a win-win situation for the government.

Ever since the passage of EMTALA, emergency physicians have been de facto employees of the federal government. We don’t get to decide whom we see. We have no way of deciding who walks in the door or whether we’re ever going to see a dime for the services rendered. We also have no way of knowing if those patients, who may not even pay the bill, are going to sue us. I think that there are multiple things that can be done right now with the Obama administration to address this issue.

The first thing is to agree that rendering care to those in need is not the problem. One of my greatest badges of honor is the ability to say that I have never denied anyone health care based on their ability to pay. We are the physicians who carry the staff of Asclepius the highest. We are the ones who, any moment of the day and night, see anyone and give out health care. This is part of who we are and should not change. But give me a break! This ought to be recognized and rewarded in at least two ways. First, emergency physicians should be able to calculate the value of the free care they were mandated to give out in a given year and then deduct some portion of that amount from their income taxes. If, in a year, I give out $160,000 of free care – which I’m perfectly happy to do – the government ought to be perfectly happy to let me at least write the loss off on my taxes. What’s wrong with this idea? I understand that this would reduce the income coming to the government, but if they actually had to pay for that same care, it would cost even more.  The federal government needs to recognize that emergency physicians are acting as conscripted government workers and should receive some sort of compensation.  Don’t give me 100%. No insurance company gives me 100% (and ever since California cancelled balanced billing none of us will ever again expect to see 100% of charges) but don’t let me drown in red ink! The logic is straightforward. As tax-paying citizens, we do not expect Boeing to make planes for the U.S. government and not get paid for it. Why would we expect physicians to give out health care and not get paid?

Second, there is no reason for EPs to bear the liability of every patient who walks into the emergency department. We need to have some reasonable liability relief. I believe that since we have essentially been named the de facto employees of the federal government, we should be covered by the federal government like any other federal employee. If the mailman runs over your mailbox, the government handles that liability. The concept is called “respondeat superior,” or “let the master answer.” Well since our master, the federal government, has decided what we will do and what we will get, let him also be involved in the malpractice issue. For physicians of any specialty who are mandated by law to see ED patients, liability should be handled through a no-fault system paid for by the federal government. In some states, this might mean as much as $40,000 savings in insurance costs. Having a federal system that would, without fear or favor, use a no-fault system to evaluate harm and properly compensate patients who are truly damaged, would work out for the benefit of physicians and patients alike.

And finally, it has been estimated that less than 15% of the funds that go into malpractice insurance policies actually wind up in the pockets of patients. Most reasonable physicians could look at a situation and decide whether a patient was truly harmed by the actions of other physicians. So be it. But do not let 40% of the money go directly into the pockets of attorneys. Both plaintiff and defense attorneys strip us down for money. Do not let people who are on the fringes of health care continuously drain the pockets of emergency physicians. It just doesn’t make sense. A simple act of assuming liability and creating boards which look at the extent of injuries would go a long way towards lowering health care costs, making physicians more comfortable with their clinical decision-making and stopping the mindless ordering of tests which are part of the “cover-your-ass” medicine which supposedly protects us from lawsuits. These few simple actions could be just the teaspoon of sugar needed to help the bitter pill of health care reform go down smoothly.

Greg Henry, MD, is the founder and CEO of Medical Practice Risk Assessment, Inc. Dr. Henry is a past president of ACEP and directed an ED for 21 years.
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Healthcare Debate: The Kennedy/Dodd Bill

This is the 2nd article of 3 from Emergency Physicians Monthly on healthcare reform issue.

Please also see the GREAT comments to this important article.

The Kennedy/Dodd Bill: A Physician’s Analysis
The Senate Health, Education, Labor, and Pensions Committee, chaired by Sen. Chris Dodd (D-Conn), passed a health bill on July 15th that finally laid out the specifics of the biggest overhaul of health care in history. You can read a staff draft of the bill HERE (text file). Here are the highlights.
by Mark Plaster, MD
Executive Editor
First, everybody has to be in a “qualified plan” as defined by the Secretary of Health and Human Services. If you can’t prove that you have been insured for every month of the last year, you’ll be assessed a surtax to cover the government covering you. Of course, if you don’t pay taxes, as an increasing number of people don’t, it won’t effect you. If you are an employer, you have to pay a minimum percent or dollar amount of the premium for the plan, but only if you don’t already offer insurance to your employees. If you do, and the plan is ‘qualified’, then you don’t pay the surtax. And how much is the tax? Whatever the Sec of HHS deems is necessary to get everyone to participate.

But what defines a “qualified plan”? The Kennedy bill mandates guaranteed issue and renewal. Everybody can get insurance and nobody can be canceled, regardless of your past health or your lifestyle choices. The plans could not charge more for people who engage in increased risk lifestyles or habits, such as alcoholism, drug addiction, obesity, etc. Each qualified plan must have a modified community rating to pay more to areas of the country where medicine costs more. There can be no caps on annual or lifetime benefits. And family policies must cover ‘children’ up to age 26. Qualified plans must have at least three levels of cost sharing, cover a list of preventive services approved by the government and cover “essential health benefits,” as defined by the new Medical Advisory Council (MAC), who would be appointed by the Secretary of Health and Human Services. The MAC would have control over such services as out patient care, emergency services, all hospitalization, maternity care, mental health, pharmaceuticals, rehab, and any other services that it deemed essential to health. The MAC would also define what was “affordable and available coverage” for different income levels.

The Kennedy bill would expand Medicaid to cover everyone up to 150% of the poverty level, with the federal government paying for all the increased costs to the states. People making between 150% and 500% of the poverty level would be subsidized by the government on a sliding scale. To put that in perspective, a family of four making $110,000 would still get a small subsidy. People living in big cities would get larger subsidies. Of course, this Committee has no ability to write actual tax law to fund this legislation. That’s up to the finance committee.
The largest of all the hurdles in the bill is the “public plan option,” in which the government will offer to include people in Medicare. To sweeten the offer, the legislation calls for physicians to be paid at Medicare rates plus 10%. The legislation makes no mention of the future payments. Nor does it acknowledge that the Sustainable Growth Rate calculations for physician reimbursement from Medicare are currently calling for a 21% cut in compensation. Group health plans with 250 or fewer members would be prohibited from self-insuring, leaving ERISA to big businesses.
The legislation calls for health insurance to be sold through “gateways” set up by state governments that market only “qualified plans.” These “gateways” would have “navigators”, also paid by the state, the enroll people. The organizations receiving these funds could be community organizer groups or unions.
As previously stated, an interesting loophole exists in this bill that would exempt health insurance plans that met the standards of a “qualified plan” that were in existence before the legislation. The effect of this could make it very difficult to change jobs, if the new job was paying the higher cost of mandated insurance.
Another huge hurdle is the definition of who must get insurance. The bill defines an “eligible individual” as “a citizen or national of the United States or an alien lawfully admitted to the United States for permanent residence or an alien lawfully present in the United States.” This appears to open the door to medical coverage to every illegal alien who is granted some type of amnesty.
The only hope for controlling costs in this bill is the re-introduction of the gatekeeper concept that was tried 20+ years ago. Under this scheme, the gatekeeper, called a “medical home”, is a patient’s private practitioner would have the control of whether a specialty referral was made, tests were ordered, or hospitalization occurred. He would have 10% of his compensation held back each year until it was known whether he met the limits on spending on each patient. If he failed to meet the spending goals for each patient, he would have to pay for the care from his own pocket.
What are the potential effects of the Kennedy-Dodd bill, should it pass? First is the price tag. Those who pay most of the tax revenues of the country would see their taxes rise significantly. Businesses will have to incorporate these increased costs by lowering wages, hiring fewer people, or moving to other areas of the globe. Small business could be hardest hit, though there is talk of a small business exemption. But it is unlikely that tax increases on the upper income taxpayers would be enough. President Obama has already started to reverse his campaign pledge that those making less that $250,000 “would not see [your] income tax rise one penny.” He is now admitting that medical benefits would need to be taxed. So if someone making $80,000 per year was receiving a $10,000 per health plan, he would be taxed on $90,000, thereby increasing his taxes up to $2,000 without any increase in salary.
The biggest effect would be 50 million new patients. With the current saturation of many private physician practices, many of those patients would come to the ED.  Convincing gatekeepers to refer and specialists to accept these patients could get significantly more difficult, exacerbating wait times and holds.
Another huge effect would be the power of the Medical Advisory Committee. Unelected, virtually unsupervised individuals would control what health care looked like in this country, who was covered, who paid, and what services were covered at what compensation.
Cost shifting from the healthy to the unhealthy and those who engage in risky lifestyles would increase dramatically. The only control of this would be through lobbying the members of the MAC.
And finally, this bill would not effect members of Congress despite Mr. Obama’s campaign promise to offer Americans “the same kind of coverage that members of Congress give themselves.”
Mark Plaster, MD, is the Executive Editor of Emergency Physicians Monthly
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Healthcare Debate: The Wrong Questions

This the 1st of 3 brief articles written by physicians regarding their concerns with healthcare reform:

“The Wrong Question” Print
by Mark Plaster, MD

I sat transfixed reading the email from a friend. I couldn’t believe what I was reading. Finally my wife broke into my thoughts. “What are you doing? I’ve been calling you for ten minutes. And when I find you, you’re staring at the computer, shaking your head and mumbling.”

“I can’t believe what I’m reading,” I mumbled. “This health care debate has turned everything on its head.”

“What ARE you talking about?”

“You know that story I used to tell about calling that lazy urologist up late one night? I asked for his help to cath a patient with a stricture and he says, ‘How old’s the patient?’. When I tell him the patient’s 81, he just growls “He’s peed enough,” and slams down the phone. Do you remember that story?”

“Yes,” she said with a scowl. “I hate that story.”

“Well, that seems to be the new strategy for reducing the cost of health care while extending it to the uninsured. This article that David sent me is about a guy who feels guilty for getting treated for his prostate cancer.”

“I don’t get it.”

“Yeah, he says maybe he should’ve just died and saved the money for the system.”

“That’s kind of twisted,” she said with a shrug. “I can maybe see someone deciding to forgo treatment if there isn’t any hope of recovery.”

“That’s OK if you are deciding for yourself. But this guy got his treatment. He has a good chance of full recovery. And now he’s trying to guilt other people into forgoing treatment in the interest of saving money.”

“Just for the sake of argument . . . ” she started.

“I can always depend on you to be the devils advocate. I can see you starting to sprout horns already.”

“No, seriously,” she said, “haven’t you always said that people spend more in the last year of life than in all the other years combined? Couldn’t the system save a lot by foregoing a lot of needless treatment?”

“Who says it’s needless? You never really know if a treatment is going to work. What doesn’t work for one person might work just fine for you. I don’t want anybody making that decision for my life, but me.”

“But what if you are too senile to make that decision,” she said, starting to warm to the debate. “You wouldn’t want us to spend everything we had on every unproven treatment, would you?”

“I will concede that we shouldn’t be using insurance money to pay for treatments that have not been shown to work. But if I’ve been paying into the system all my life, shouldn’t I get a chance to try some experimental treatments?”

“Well . . . ”

“And I hate it when you throw the ‘senile’ thing at me.” I furrowed my brow and gave her a suspicious pout. “There’s nothing wrong with a little senility.”

“Oh, come on. You don’t want to just sit around in a nursing home and drool like that lady you used to tell me about, the one you had to change a diaper for all the time.”

“The lady you’re talking about was named Gladys and she seemed perfectly content to smile, drool, and poop in her diaper. Like I said, there’s nothing wrong with a little senility. The fact is that I’m sort of looking forward to a little dementia. I want to live with one of our kids when I get senile. It will pay them back for all the years that I changed their diapers.”

“When did you ever change a diaper?” she snapped back.

“Do you remember that time that we were…you know…having a little roll in the sack and one the babies started crying. And you ran in and brought him to our bed and he threw up on me. Do you remember that? Talk about ruining the moment.”

“Talk about holding a grudge,” she said shaking her head.

“I can still feel the sensation of baby vomit running down my bare legs. I spent the rest of the night picking chunks of beets out of my chest hair.”

“That made quite and impression, didn’t it?”

“It’s a nightmare I’ll never forget,” I said, mocking her mocking me. “I’m just saying that we took care of the kids when they were babies. Why shouldn’t they take care of us when we are old.”

“OK,” she replied slowly. “But you lost me on how this relates to the health care reform debate.”

“Don’t you see? The whole debate is turning things upside down. People who haven’t paid anything into the system are claiming that they have a right to healthcare. And people who have been paying into the system for years are being guilted into refusing to take what is rightfully owed to them. The throw-up story was just a colorful aside.”

“But you’re not denying that we spend a disproportionate amount of the total health care expenditure of the country on the elderly?” she said trying to score a minor victory.

“OK, maybe we do a little. But all kidding aside. Every day of every life is valuable. And we shouldn’t be pitting one group against another in an effort to balance the health care budget. It’s not a zero sum game.”

“Well, one thing’s for sure. The country can’t continue to spend more and more on health care.”

“Do you hear what you’re saying? You’re beginning to sound just like all those bureaucrats in Washington. People should be able to spend their money on whatever is important to them. It’s pooled insurance money, or worse, government insurance money, that has people thinking that how they spend their health care dollar is the business of other people.”

“So you would like to see us go back to a purely free enterprise medical system? First, that’s not going to happen. This isn’t the 50’s. And second, what would happen to the people who don’t have enough to pay for expensive medical care. I know that you can be a cold, heartless, S.O…”

“Hey, don’t start talking about lawyers again.”

“… but I don’t think you are advocating cutting people out of the system.”

“Of course not,” I said, becoming serious again. “There’s more than enough excess in the system to pay for truly needed medical care for everyone. And if you want something that has marginal value, you should be able to get it. But you should have to pay for it. If you can’t afford something that has marginal value, then you shouldn’t get it. It’s that simple.”

“It’s that simple, huh? You seem to have it all figured out. So why is Congress having such a tough time with this?”

“They’re asking the wrong questions. And they are pitting one group against another, like they always do.”

“There’s just one question remaining, smarty pants. Who is going to decide what is ‘truly needed medical care’?”

“We are,” I said confidently. “Physicians are the only ones who can make that decision. All we need are education and ethics. The basics. And we need protection from the lawyers when we have to make a close call or when a bad outcome occurs.”

“Now you’re the one talking about lawyers.”