Tuesday, July 31, 2007
What happens if you lower physician salaries?
Well, the best and the brightest will no longer be inclined to enter medicine. Is that really what society wants?
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The deterioration of "free" care in Canada
Physicians are demanding access to private care options in Canada:Canada's doctors want to be able to work simultaneously in both the public and private systems, a flexibility that critics say could lead to queue-jumping and further depletion of public health care.
It's also a proposal that puts the medical community on a collision course with Prime Minister Stephen Harper, who argues that physicians would have an incentive to stream patients into the private portions of their practice.
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Kidney transplants: Paying it forward
The concept of paired donation. (via Freakonomics)
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Torture inside the Libyan jail
The recently freed doctor gives a harrowing account of the ordeal:The Palestinian doctor who was held in Libyan custody along with five Bulgarian nurses on charges they infected hundreds of children with HIV, has described in detail how they were tortured during their eight-year ordeal. Ashraf Alhajouj, 38, said he was beaten, held in cages with police dogs and given electric shocks, including to his private parts. He said that he and the nurses were sometimes put together naked in the same room and tortured.
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Paying doctors by the hour
"Pay by the hour is the most difficult method to game," says Half Sigma. Makes sense, but without any productivity incentive, appointment shortages may become more dire as the longer visits will fill more physician schedules.
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Single fathers and their children's office visits
Apparently children of single dads make less well-child visits.
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Drug reps on doctors: "Everybody has a price"
More drug detailing tactics:"It's my job to figure out what a physician's price is. For some it's dinner at the finest restaurants, for others it's enough convincing data to let them prescribe confidently and for others it's my attention and friendship... but at the most basic level, everything is for sale and everything is an exchange," stated former Eli Lilly drug rep Shahram Ahari.
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Foreign doctors and US health care
A USA Today op-ed:I tell you these facts because of the knee-jerk reaction I hear that we should take measures to prevent the entry of foreign-born physicians. This would be a disaster for American health care, and it would not make us safer. We need to increase physician immigration and increase the supply of U.S. medical school graduates. Otherwise, we'll face a future of rationed health care.
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SCHIP and Medicare fee reductions
Hidden in the debate over expanding the SCHIP is the fact that the impending Medicare fee cuts will also be abated:The bill's main Medicare proposals include replacing the impending 2008 and 2009 physician fee cuts (projected to be 10 percent and 5 percent, respectively) with a 0.5 percent update for both years.
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"The AMA is proud of Dr. Pou"
The AMA comes out in support of the dropped charges:"The AMA continues to be very concerned about criminalizing decisions about patient care, especially those made during the chaotic aftermath of a disaster, when medical personnel and supplies are severely compromised."
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Pharmacists sue over Plan B
An "opt-out" clause wasn't enough to satisfy these pharmacists:Pharmacists have sued Washington state over a new regulation that requires them to sell emergency contraception, also known as the "morning-after pill."
In a lawsuit filed in federal court Wednesday, a pharmacy owner and two pharmacists say the rule that took effect Thursday violates their civil rights by forcing them into choosing between "their livelihoods and their deeply held religious and moral beliefs."
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Placebo Television
A hilarious weekly vlog from the writers of Placebo Journal. "Scrotox" is classic.
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Talking about statins
Benjamin Brewer considers the questions when treating high cholesterol. (via The WSJ Health Blog)
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Pfizer: Going to the dogs
Having had setbacks with torcetrapib and Exubera, and with generic competition to Norvasc and Lipitor, Pfizer is putting more emphasis into animal drugs.
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Clogging the ER
Scalpel on flow-stoppers:Any patient who requires an interpreter, any time-consuming procedure, patients who are overly demanding, patients with numerous concerned and annoying relatives, patients who want to be admitted but don't need to be, patients who need to be admitted but don't want to be, patients requiring more than one or two calls to other physicians, and so on.
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Variance of care and race
Physicians aren't racist, says Chris Rangel. It's about where people go for care:. . . the poor mostly seek care at urban health centers that tend to be underfunded, understaffed, and overburdened. It's basic economics. Poor people tend not to have the same access to the same quality of housing, cars, consumer products etc. that more affluent people do and health care is no exception . . .
. . . But liberals are too quick to play the race card when it comes to the unequal care given to the poor. This option is much more palatable for them than to face the realization that their oft vaunted public health care systems may be much more to blame.
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Investing in primary care
"Sometimes you have to invest money to make money," says Robert Centor. Can generalist care be saved?
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Treating friends or colleagues
A case where atypical depression was missed - due to the celebrity or VIP bias:Dr. Groopman observes that V.I.P. or celebrity patients sometimes short-circuit the physician’s normal diagnostic thinking. For example, these patients may be spared the doctor’s usual tests and procedures. As our “top gun,” Mike was just such a patient to me. Even as I entertained grandiose fantasies about curing him, my unconscious may have steered me away from doing everything I could to help him get better.
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"Take two tablets twice daily"
What does that mean to you? More patients than you think are confused by drug labels:Did that mean a total of two, or a total of four? A third of patients who were deemed literate got confused. A more clear instruction would be: "Take two tablets in the morning and two tablets at night."
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Hastening death to procure organs
Sick. A doctor is charged with facilitating the death of a man to harvest his organs:A San Francisco transplant surgeon was charged Monday with prescribing overdoses of medication to speed up the death of a man at a San Luis Obispo hospital and harvest his organs.
Dr. Hootan Roozrokh, 33, prescribed excessive amounts of morphine and Ativan and injected the topical antiseptic Betadine into Ruben Navarro's stomach in February 2006, prosecutors in San Luis Obispo County said. Navarro, 26, who was severely disabled mentally and physically, had suffered respiratory and cardiac arrest and had been taken off life support, authorities said.
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A reprieve for Avandia
A panel stops short of pulling Avandia from the market.
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Grand rounds is up
Health Business Blog hosts this week. Come get the weekly best of the medical blogosphere.
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Monday, July 30, 2007
Government-run or free-market?
The answer is irrelevant unless costs are contained:The problem is that nobody is going after the root causes of the spiraling cost of care. To simply call for “more free market” or a “single-payer system” without addressing the incredible waste, lack of accountability, and profiteering by third-parties is simply re-arranging chairs on the Titanic. It is the unfortunate nature of politicians to take a politically-motivated veneer and layer it on top of a broken system and call it fixed.So, lets get to the meat of it. Why are health care costs so high? The amount of tests we order plays a large role. Why do physicians order so many tests? Fee-for-service reimbursement, defensive medicine, and patient demand.
Why not address these core issues? Well, a platform of putting doctors on salary, tort reform, and rationing care is a sure way to finish last in the Presidential race.
So in the end, nothing gets solved.
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Mastectomy
Immediate reconstruction or not? Sid Schwab weighs in:But having treated many hundreds of women with breast cancer (I lost count a long time ago) and having been (so I was told) more sensitive to the horror and fear than the "typical" surgeon, I feel qualified to express myself. My thoughts are based in the reality I saw in my practice. So here it is: though not opposed, and having participated in many cases of it, I'm not a big fan of immediate breast reconstruction after mastectomy.
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Avandia may be going down . . .
. . . and is Glaxo trying to take Actos with it?
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Paying for your obesity
Health insurance premiums are starting to be linked to lifestyle habits:Government workers in Benton County, Ark., can now sign up for a plan with premiums that fall from to $500 a year from $2,500 a year if they maintain a healthy weight. Clarian Health Partners, a hospital chain based in Indiana, said last month that it’ll start charging workers as much as $30 every two weeks if they don’t get their weight down. And UnitedHealthcare introduced a family plan this month that has a typical deductible of $5,000–but it falls to $1,000 for people who maintain a healthy weight and don’t smoke.Nothing like hitting the wallet for incentive.
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Seasonique ad misinforms
The Well-Timed Period critiques this DTC effort:I realize that a TV ad is expensive, the time is limited, and the ad's function is to convey a marketing message not to educate. But that's no excuse to misinform.
It's like there's this implicit assumption out there that we mustn't trouble potential Pill users with too much information. And that really annoys me. Explain the difference between a period and withdrawal bleeding and watch the confusion cause women's heads to explode. Tell women they don't actually have periods while on the Pill and avert your eyes while the shock of the revelation paralyzes them into grotesque poses.
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Why are there so many hysterectomies in the US?
A microcosm of the procedure-driven nature of American medicine.
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Infants in obesity clinics
Patients as young as six-months old are showing up.
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Dr. Anna Pou: "The grand jury did the right thing"
Louisiana physician-blogger Michael Hebert with his thoughts on the Anna Pou story:One final question the reader may ask: Do I think Dr. Pou did it?
I don't know Dr. Pou personally, but I do find it difficult to believe that a doctor educated in the United States, knowing the law as all doctors do, would have tried to do something like this. It would have been much easier for her to simply sedate the patients with the aim to relieve pain. She had no obligation to kill them, and, in fact, with sufficient morphine on hand to keep pain at bay, no need to kill them either. She could have managed them to to the point of natural death without having to make such a terrible decision. So on balance, I would have to say probably not.
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Physician websites
A doctor who doesn't have a strong web presence will be at a huge disadvantage as patients rely more on the web for their health.
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Is it time for doctors to hire publicists?
As medicine continues to evolve to a business, physician "branding" becomes more important:"The secret is being bigger than your medical practice," says Howard Bragman, founder of the media and public relations agency Fifteen Minutes (whose clients include Robert Rey, a.k.a. Dr. 90210). "If the only money you ever make is doing your medical practice, you're limiting your income. If you can make money selling products or with books, then you become a brand."
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Defensive medicine in the news
Anyone who reads this blog knows what I think about defensive medicine, and how I feel it is one of the leading factors in rising health care costs today.Two articles in the news highlight this. The first one suggests that defensive medicine practices are spreading to paramedics:
"I think that for most physicians now, it's the fear of being sued for missing a diagnosis," said Scott Maizel, a surgeon at the Sandra and Malcolm Berman Comprehensive Breast Care Center at the Greater Baltimore Medical Center and former president of the Maryland Chapter of the College of Surgeons. "Physicians are now performing more tests, (writing) more referrals and frequently require more visits back to the doctor to make sure nothing was missed."The second asks some questions that policy wonks and lawyers seem to ignore:
Besides physicians, many prehospital professionals are also taking precautions.
Ocean City Fire/EMS Capt. Charles Barton said while liability for prehospital care is lower for EMTs and paramedics, there is still concern.
"I think most people are concerned about liability issues," he said. "(However), risks can be managed and liability can be reduced."
Twenty percent of the time or less, more in-depth testing and treatment is required.(These are called"zebras" - which are uncommon.) "Defensive medicine" is when those extra tests, procedures and treatments are done on the common illnesses(zebra tests on horses). Why are they done? Primarily to avoid being found "negligent in a malpractice court."
What is the cost of these additional tests?Hence, the real costs of malpractice avoidance? How many lawsuits are initiated by people(or their lawyers) seeking "easy money"? Often, these are "settled" just to avoid the high costs of court procedures plus the emotional and time costs, but no malpractice has been done! What are the "costs" of these "frivolous lawsuits?" How much time and energy have you spent trying to "fight" a traffic ticket? What were the costs?
But just the experience of being "sued for malpractice" will push the health-care provider to practice more defensive medicine. At what cost to the health-care system? Surely more than 2 percent.
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Free health care: "People do not realize how much they pay for it in taxes"
More Sicko rebuttal:Why then, is national health insurance in other countries as popular as Moore says it is? One reason is that people do not realize how much they pay for it in taxes. Even mediocre care looks good if you think it is free.
A second reason is that doctors in other countries often don’t tell their patients their care is being rationed. Instead, they say, “There’s nothing more we can do.”
A third reason is that most people are healthy. Relative to U.S. levels of provision, countries with national health insurance routinely underprovide to the seriously ill and overprovide to patients with minor ailments. Thus, the scene where patients in Canadian waiting rooms are asked how long they had to wait, and they all reply with times under an hour.
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The office visit: It's all business
What he writes is true:At last, you're ushered into an examining room. The change of venue lowers the level of your fuming. The nurse orders you to strip and don a hospital gown so that the doctor can give you his immediate attention. All this indicates that his arrival is imminent. In fact, as the nurse leaves, she says, "The doctor will be right in." And he is - 25 minutes later.But as I said before, don't hate the players, hate the game.
When the doctor does come in, he gives you his undivided attention - for all of 15 minutes. This is your chance to "talk to your doctor," as they say in the pharmaceutical TV commercials. And this is the time to ask if a certain medicine you've seen advertised on TV is for you.
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The death of primary care: The numbers tell it all
An editorial by the numbers - and this is supposed to entice medical students to choose primary care?
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Dentists gone wild
A dentist puts fake boar tusks in a patient's mouth while she was under anesthesia.The story gets better as he profited from this whole shenanigan and had the state Supreme Court involved:
In a sprightly 5-4 decision, Supreme Court Justice Mary Fairhurst wrote that Woo's practical joke was an integral, if odd, part of the assistant's dental surgery and "conceivably" should trigger the professional liability coverage of his policy.Read more about the Gone Wild series.
Dissenting Justice James Johnson said the prank wasn't a dental procedure at all and only "rewards Dr. Woo's obnoxious behavior and allows him to profit handsomely."
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Salaried physicians are lazy doctors
If there's no incentive for productivity, many physicians will go to banker's hours to the detriment of patients:The problem with a flat salary is that there's no incentive to maximize work. Show me a salaried doctor (without a productivity bonus) and I'll show you one who believes strongly in his right to get home by 5PM, regardless of medical problems coming through the door, or over the phones, that day. This translates into doctors who send acute problems that could be handled in the office to the emergency room to avoid hampering their own schedules, doctors who schedule longer appointments, or block off time to allow extra time for paperwork during the day.
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The NHS is just one big HMO
Something to consider for those who advocate government-run health care, it will be more of the same:Three quarters of GPs who referred patients to hospital have had their decisions blocked, a poll for The Sunday Telegraph reveals.Update -
Family doctors say that new "referral management" systems, set up to allow primary care trusts (PCTs) to overrule decisions taken in the surgery, are being used to delay and cancel hospital care, and to divert patients referred to a hospital consultant to cheaper clinics in the community.
Dr. RW correctly says that a single-payer system will just be managed care on a national level:
It’s ironic that the proponents of a national health care system in the U.S. try to bolster their arguments by citing the evils of managed care, that monster we all love to hate. But national health care, in whatever form it may ultimately arrive here will, likely as not, be a system of heavy managed care under multiple layers of intrusive government bureaucracy---everything we hate about managed care and much more.
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Manipulating P4P
Stanley Feld writes about P4P and how insurance companies are going to destroy the physician work force:Just imagine the worst physician in a community figuring out what tests would give him a high rating and increase his income. He does the required tests routinely whether the patient needs them or not. He misinterprets those tests to the detriment of the patient. Yet he is rated the best doctor in the town. It is like a bizarre Fellini movie.
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"The unholy combination of coronary artery disease and drug addiction"
Chest pain from cocaine, clouded by real heart disease. Nurse K on this regular visitor to her ER.
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Is universal health care worth the long waits?
What Sicko conveniently left out:In Canada, McCreith’s story reflects a debate, intensified by the long waiting times, between those who want more for-profit, private care and those who fear the rise of two-tier medicine that undermines the public system.
McCreith offers little doubt about where he stands. “We have universal health coverage,” he said. “But it failed me when I needed it the most.”
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Suing for an infiltrated IV
A woman's peripheral IV infiltrated while giving birth:Memorial Hospital of Belleville and a nurse are named in a medical malpractice lawsuit filed by a woman who claims she sustained IV infiltration while delivering a full term infant.(via Radical Doula)
Trecia Lash alleges that on July 29, 2005, the hospital and nurse Debra Sakho failed to recognize her distress after she complained of severe pain at the intravenous infusion site in her left hand.
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Fires in the OR
Guidelines are being proposed to address this:The proposed guidelines include lowering the concentration of oxygen given to patients during surgery by diluting it with room air when surgical tools that could ignite a fire are in use. Other suggestions are to reconfigure drapes to minimize oxygen buildup and use suction devices to remove excess oxygen from surgery sites.
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Dr. Crippen takes a break
Well deserved. See you back in the fall.
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When you switch to Medicare
Why physicians are closing the door on Medicare patients:What you soon-to-be Medicare patients don't realize is that when you turn 65, your doctor automatically gets paid about 30% on average less money for the exact same office visit with you, compared to when you didn't have Medicare. And it's illegal for you or your doctor to negotiate any fee higher than "Medicare allowable." How many doctors with full practices will be anxious to add new Medicare patients into their slots, which could be filled with non-Medicare patients paying 30% more for the exact same work? The answer is, Not Many, and therein lies a huge problem most people nearing 65 aren't even aware of.