I am tired

Hello, I recently started a new job, I can now help the under served without worrying about getting paid, that is right, I now provide medical care to patients at the state psychiatric hospital.

I am tired however, quite tired of the battle for equitable health care. I have blogged, joined organizations, signed petitions, called my representative politicians, written letters to the editor, spoke to groups/organizations, written a book, argued, debated and screamed. I will never understand why a profession, whose very roots demand that we are here to serve the human race, to battle suffering and promote health, is so hotly debated as an economic issue!! I understand medical economics better the most, but not as well as some, and yet I can't see why people can not get past their "ideas" of how it "should" be?? To quote an author from a favorite book, "as long as ideas are more important than people, we will continue to kill people and let them die in the name of our ideas". I truly do not believe that anyone of the people who continue to make the economic argument for "free market" health care could look into the eyes of someone who is dying (or their family for that matter) from a treatable disease that likely would have been prevented through an equitable public health system and still argue for "free market" health care. If they can do that, than all is lost and I will have to personally reinvest in Thomas Hobbs' book "The Leviathan" for in this case, we are all self serving, uncivilized monsters, and not only have we not evolved past public displays of lions eating people, we have actually devolved to watching our brethren die and suffer right next to and in front of us in the name of personally retained resources.

Here are some of the organizations that are fighting for healthcare reform with different agendas.
Code blue
Health care grass roots
PNHP
AARP
Health Care Now
SEIU
AMA
Families USA

This is just a short list!!! there are many, many more, we are all advocating for changes in the health care system, all with different agendas for different reasons. I am tired, as a one time mentor said to me, "that's like shoveling shit against the tide" and so it is.

Well-Care?

Yesterday, there was an excellent post at the "Health Beat Blog" by Maggie Mahar, in this post there is an excellent conversation between Maggie and Brian Kleeper here . I have to admit when I first read Brian's piece I was angry, but his overall point is sublime. Primary care has not united, taken the bull by the horns, or done anything to control their medical destiny, and in doing so (or not doing so as it were) they have left the door open for, and should fully expect such market driven medical clinics.

I must take just a few lines to discount some of the "advantages" as put forth by Brian, however I am doing so from a medical point of view, as opposed to Maggie's response which was more of a economic response.

First is the EMR, or electronic medical record, which is touted by him, and many of the com mentors as a way to improve efficiency in medicine both by tracking treatments and physician performance. If anyone reads my book (besides me that is) you will learn some interesting points about EMR. I am not against them, but I am an open critic. First, EMR is expensive, the software and licensing can cost up to 50K a year, being such they are designed not so much to support evidence based medicine but to support maximization of billing. Think about it, they are sold to administrators, in such the sales pitch doesn't talk about maximizing outcomes for obesity, they talk about how it will pay for itself in such in such a time. Speaking of outcomes, there are no, and I mean NO evidence based studies that show improved outcomes when the use of EMR is initiated!! I am not sure we would spend 50K a year anywhere else in medicine on unproven technology. I suppose I could write this whole blog on EMR (in fact I know I can), I will add just one more observation, as part of my current job I read medical records from all over the state, all day. The records that are the easiest to read are from EMR, but they are also the most inaccurate with the most internal inconsistencies, they are only as good as the tenacity of the person inputting and updating data GIGO (garbage in garbage out).

There are some serious ethical concerns with the a clinic that your boss pays for, chronic disease, recurrent illness, work place injury, drug and alcohol abuse, these medical/social topics being investigated and treated at your work place, by someone who works for your boss is well.......slippery to say the least. Maybe as a large employer the stats that I gather will cross reference with productivity, I will realize quickly that any employee with more than three to four visits a year is generally less productive?! Being that I am bound by law to work for my investors wouldn't I use this information to "weed out" less productive employees! There are many concerns here, the corporate world is not monitored closely enough to be trusted to operate such clinics.

Finally, in Brian's piece he writes about high performance and efficiency, I can't be sure but these terms seem to be applied in the economic sense, he did not quote any health outcome statistics. When we are talking about your health and the health of your loved ones, we should never stray from health outcome stats, never ever. Granted, statistics that help us maximize resource allocation should be considered and are incredibly important, but not when applied for the maximization of profits, it won't be in your best interest.

Brian is right though, primary care has failed to stand up and shout. We have not stood back to look at the big picture and said, "Yes, doing something to improve our situation will overall benefit the patients, and the community" we are cowards!! We are afraid to rock the boat.

Band-Aids and Prop-ups

Now that I have taken a livelier role in the debate on health care and health care reform I have learned a great deal from the arguments of those who think a business model of medicine is the best cure. Knowing the arguments of both sides of any debate helps you understand not only the weaknesses of your own position (if you are open to it) but also the strengths and weaknesses of those who stand firmly in opposition.

It seems to me that one of the major arguments for pro-business medicine has been the constant finger pointing at government programs with all its bureaucracy, wasteful spending and the unintended consequences associated with such. These are good points, where the government has stepped in for health care; reimbursements are low, covered services are nonsensical, red tape is at the maximum, requirements are unbelievable and potential for abuse and waste is……well, more than potential but reality.

Upon pondering these points and reviewing the spirit of all the government health care programs that I know, the obvious and hardly mentioned point hit me. All government health care programs, right from the beginning and to date have been formulated for the sole purpose of patching holes in the business model! This is no example of government run health care, this is the government supporting in a rather covert way, business run health care. Medicare was formed because non of the insurance companies wanted to cover the elderly, they are a significant profit risk, Medicaid was for the poor that the insurance companies wouldn’t cover, EMTALA is for emergencies that the private hospitals otherwise wouldn’t provide care for, critical access hospitals are for the areas of the country where hospitals wouldn’t be profitable thus would not be built, HIPPA, COBRA, it goes on and on. Really what we are talking about is prop-ups and band-aides designed to fill the voids and gaps where a business model would have left a much greater portion of the American population “out in the cold” when it comes to health care.

I propose that if the government had not stepped in with band-aids and props the public would have revolted long ago for a more palatable health care system. In fact, despite the mass tragedy of it, I think we should tear off the band-aides and props let the system collapse and allow people to see what a business model of medical care really does. OK, that is too radical; on the other hand, nothing would move us forward faster.

One other point on "free market" medicine. By all accounts that I am aware of a market is defined by a group of people who would be interested in and be able to purchase a particular product. There is no "market" that I know of that includes all people when the product is both complex and moderately expensive. So, by nature and design "free market" medicine will leave out a substantial portion of the population. Who will care for these people? I suggest anyone interested try a little exercise, go to a crowded place and decide........say.........1 in 10 people do not deserve medical care because they are not defined by the market, then you decide who they should be.

Finally, if it is not obvious at this point, I would say that the current government band-aides are no example of what a government “run” system could or would do, if you want to see that take a look at the VA system (by most accounts, quite efficient and well run). My retort then is, “government run health care that you so strongly criticize is the only thing keeping your business model of medicine afloat, which, if it needs that much help obviously isn’t working and should be scrapped, let’s sit down, your side and mine, your arguments and mine and “design” a system that we can live with and benefits us all.”

Too Much Care

In a recent article in the NYT Dr. Sandeep Jauhar, here, discusses, quiet eloquently, some of the causes and effects of too much care. For further, more in depth reading on this topic I highly suggest Shannon Brownlee’s book “Over Treated”. I would like to go just a bit deeper into the subject.
The causes of too much care are vast and interrelated, however I do agree with Dr. Jauhar that the major cause is economic, having run my practice such that I minimized the amount of treatment and intervention, thus cost (thus further my profit) I suffered financially. I of course did this because it is what is in the best interest of the patient…….or is it? Dr. Jauhar’s cardiologist friend from Long Island took the other half of this argument. The justification is this, if I don’t make enough to continue to practice the community will actually lose an important commodity? In fact when I closed, 1500 patients were left without a doctor, and in a community with a shortage, many had to wait months to get one and had to travel much further away. I will leave it up to you, which is right, more care for survival of the practice such that care can continue to be provided (albeit at less quality), or proper care for the individual? Now, the eight main reasons we are getting too much care.
#1 ECONOMIC, That’s right, you are getting too much care because hospitals, and doctor’s offices can not sustain if they don’t provide these unnecessary, expensive and often dangerous treatments and interventions. The pharmaceutical industry on the other hand is providing this in the name of pure profit, survival is not an issue, not to say that some of the docs and hospitals are not specifically profit driven, but overall, less so.
#2 DEFENSIVE MEDICINE, Without a doubt defensive medicine is happening (that is ordering tests, and investigations not based on science or statistics, but based on, “just in case” or so “I don’t get sued”) the problem with this is that docs are often unwilling to admit (at lease publicly) how much of this that they do, thus there is absolutely no way to discern how much it is costing all of us. Read my piece on Liability here.
#3 MISPERCEPTIONS, The misperception that more care is better care, this “is” a misperception. The studies reveal that where there are more specialists and specialty care, life expectancy is shorter. Dr. Jauhar’s friend gives a nice example of how this affected the cost of medicine in his practice/community.
#4 PRIMARY CARE SHORTAGES, whether you think there is a shortage or not, there is. In many communities there is a long wait to get a doctor, and to get an appointment. This is tied tightly to economics, primary care gets reimbursed the least for what they do, thus if you own a practice or hospital you want to own some specialists and “encourage” your primary care providers to “provide less and refer more”!! With long hours, low pay, and often little respect, the number of medical students opting to go into primary care is ever shrinking. More specialty care obviously means more tests and more interventions.
#5 HEALTH INSURANCE, The health insurance industry adds nothing of quality to health care; they do however add overhead costs to the doctor’s office via, complex billing procedures and prior authorization requirements. Health Insurance companies spend 70-85% of premiums on health care; however that also means that 15-30 cents on the dollar of your money goes to CEO salaries and unneeded overhead expenses. With higher overhead, doctors and hospitals are forced to perform more expensive tests/procedures to pay the bills, more on overhead here.
#6 GOVERNMENT INTERVENTION/MANDATES, Yes, though I personally believe that a single payer system is the most equitable way to spend our health care dollar, I am not blind, it is clear that govt mandates on health care and insurance have increased the cost of providing care (in this profit system that means the cost of doing business) without providing means to pay for it. I have written at TPM café about this, read the section called band aides and props if you are interested, and if you can find it. Again, anything that increases the cost of doing business increases the likelihood of doing more expensive tests and procedures.
#7 MARKETING, That’s right, marketing increases what we spend on medical care, most notably through the pharmaceutical and medical device industry but this applies throughout. Of course more contact with the doctors and hospitals because the TV told you that you might have “blank” leads to testing, intervention and treatment. Without providing an incredibly detailed argument, if marketing did not increase income (in this case money spent on health care, meds etc) no one would do it.
#8 TOO MUCH CARE, more care begets more care, one abnormal test leads to another, leads to a complication which leads to an intervention which leads to…………

I was going to go into the effects; however, my usual verbosity has inspired me to shut up now. Please note however, that anyone who purports that it is only one or two of the above causes that leads to increased cost of health care, and or the increase in testing and overall decrease in quality of care is standing in the middle of a forest and blaming a single tree for getting them lost.

Just a little fun

Woody Allen

If only God would give me some clear sign! Like making a large deposit in my name in a Swiss bank.

If it turns out that there is a God, I don't think that he's evil. But the worst that you can say about him is that basically he's an underachiever.

I don't want to achieve immortality through my work... I want to achieve it through not dying

It seemed the world was divided into good and bad people. The good ones slept better... while the bad ones seemed to enjoy the waking hours much more.

Most of the time I don't have much fun. The rest of the time I don't have any fun at all.

My one regret in life is that I am not someone else.

When I was kidnapped, my parents snapped into action. They rented out my room.

You can live to be a hundred if you give up all the things that make you want to live to be a hundred.

George Carlin

Honesty may be the best policy, but it's important to remember that apparently, by elimination, dishonesty is the second-best policy.

I'm completely in favor of the separation of Church and State. My idea is that these two institutions screw us up enough on their own, so both of them together is certain death.

If it's true that our species is alone in the universe, then I'd have to say that the universe aimed rather low and settled for very little.

The very existence of flamethrowers proves that some time, somewhere, someone said to themselves, "You know, I want to set those people over there on fire, but I'm just not close enough to get the job done."

Well, if crime fighters fight crime and fire fighters fight fire, what do freedom fighters fight? They never mention that part to us, do they?

Bob Hope

A bank is a place that will lend you money if you can prove that you don't need it.

No one party can fool all of the people all of the time; that's why we have two parties.

Liability Insurance

Let’s talk Liability. I know, I know, ughhhh! But truly, medical malpractice insurance serves a very particular purpose. It protects those of us in the field of medicine from losing everything due to a costly mistake, or maybe not…….I’ll get back to that. For perspective I will give you my specific costs. When I opened my practice (keep in mind I did do obstetrics) the medical liability Insurance company that I spoke to gave me the following quote, it will be 5K for the first year, then it will go up 5K a year for five years, after which it should level off. Huh? The explanation goes like this, in order to make a big enough mistake to get sued you have to actually see patients, the more you see, the greater your risk. So it makes sense that there should be an initial steep incline. Ok I said, can’t practice without it, well, in my state you can legally but you wont get hospital privileges, nor will any of the health insurance companies allow you to become a “preferred provider” whatever that means. So I did my projections and budget and was all set, by the way, my projections where so close to what I actually made in the second year it was scary, I was within $20!! But, then the dreaded third year began, anticipating my bill for 15K I opened the envelope only to find a bill for 22K!!!! What?! I called my broker who then reported that the state insurance commissioner had allowed a 17% increase in premiums. What? Why? Has there been a rash of malpractice suits with massive payoffs? ….no. So I proceeded to call and email and call the state insurance commissioner, funny I never did get an answer. At this point I had to take a loan to finance my liability insurance. Can you believe that? So now I was paying interest on this increase. Not long after this I closed my practice (four months to be exact).
I would like to break this down just a bit. First of all, let’s remember that insurance companies are publicly owned and traded, thus by law they are responsible to their stock holders, not their customers (I don’t think I will ever understand that). Next we need to remember that a major portion of their income is received via investments made with those premiums, rather than the premiums alone. So what is the cause of the cost and “Liability Insurance Crisis”? Depends on who you talk to, if you talk to Doctors you will here that we need “Tort Reform” because greedy lawyers and large payouts, I suppose if you talk to lawyers they will say careless doctors are the cause, and if you talk to economists the answer will be poor performing stocks. The economists will add, however that the price will continue to rise as long as the market can handle it, think of it, if you are selling widgets and you are charging three dollars, and raise the price to six and people keep buying it, why not go up. Free market should bring this down right? Maybe, if you raise your prices and increase your pay outs to stock holders, wont other insurance company stock holders be jealous, and raise their prices? It is a tedious balance to say the least. But let me tell you, as a Doctor we don’t shop around that often and we sign for a year at a time, so….they are pretty safe with my premiums for a year. One of the reasons we don’t shop around is a little thing called “tail”, what? Most of today’s medical liability insurance is a “claims made” policy, that is you are covered for claims made while the policy is in effect, when you are done or want to change policies you will have to buy tail coverage for anything that happens later, i.e. if I missed breast cancer during an annual exam, after which I cancelled my insurance, then three years later the patient finds out she has breast cancer and decides to sue me, even though I was covered when I examined her, I am not covered now, unless I bought “tail”, incidentally the bill for my tail coverage after a mere 2 ½ years of practice was $53,000.00!!!!!!!! This, among other things provides market stability, if you want to change insurance companies you better have a few bucks saved up. By the way, I didn’t buy the tail, so if a law suit comes up latter I can lose everything I have, kids college fund, house, car, etc. etc.
Now, let’s talk a little about Tort reform, this basically means let’s make laws that A. make it harder to sue, and B. decrease pay outs when a law suit does go through. Sounds like it will help right? Nope, In the states that have passed tort reform (NH, ME, TX, among others) there has been no change in premiums whatsoever. So why are docs screaming for tort reform? Look at the share holders, presidents, board of trustees and CEOs of many of these liability insurance companies, I looked at the top six, this group is filled with Doctors!!!!!!!!!!!! Talk about a conflict of interest. Tort reform is good for insurance company profits and bad for people wronged by the system (probably bad for trial lawyers as well).
Now back to my “mistake” here is how it actually works, medical malpractice law suits are decided by juries and usually it is an emotional decision (that is why obstetrics fares so poorly, “everybody deserves a healthy baby”) also based on “standard of care” not based on evidence or science. So as a professional I must make decisions with you in your best interest based on science, but if that is in conflict with “standard of care” I am at risk, and if it goes to court, at fault. Here is an example, all the current evidence reveals that the use of a PSA test (for prostate cancer) is a poor screening tool and not only does in not change outcome, it may actually cause harm, however, because it is standard of care, if I don’t order one, then you end up with prostate cancer, you can sue me and win!.
Finally, I would like to mention the disempowerment that having liability insurance creates. Not only do I have no control over the premiums, nor can I practice without it, but if I get sued they decide whether or not to actually fight the suit. So, if it is financially equitable to settle out of court, that is what they will do, without regard to my good name or reputation!!! I was going to quote some of their profits, investments, payouts etc, but this got long winded, and this info is available online, just google it and look for annual reports.

I'm Back

This is a short post to inform my readers (if there are any) that I am back. Over the last several months the love of my life and I were blessed with a baby boy, and, well he is a pain in the butt. We haven't slept much, slept together or seen each other much trying to juggle work, the other children, fair sleep and the cranky baby!!!
I would like to take a moment to note that I have made some changes and intend to post more regularly. I am looking for a dialogue, not a monologue. I hope for meaningful interaction, and though occasionally agressive I have no issue with having my beliefs challanged, this is how I learn, change and grow. So, let the games begin.