I don't have much to add to the medical blogopshere's discussion on the upcoming, landmark Supreme Court decision, so instead I'll point to two reasoned posts, arguing the case from opposite sides.

Find out how this rural physician uses a dose of Twitter and a USB drive to research articles from medical journals. A change from the old days of going to the local medical library and waiting in line for the photocopier.

It also makes one realize how academic physicians can take access to medical literature for granted. In rural areas, articles are expensive to come by.

More community health centers:

Family Health Center cuts its ER visits by 15 percent from 2006 to 2007 after creating a nurse triage system and adopting appointments for its urgent care department. Overall, ER visits dropped by 2 percent at the 21 health centers participating in a state initiative.

Finding physicians to staff community clinics is another matter, but the bottom line is that increasing outpatient medical access will relieve emergency department crowding.

If you think the consequences are tough here, you haven't seen this case in Saudi Arabia:

Egyptian Raouf Amin languishes in a Saudi jail and is punished with 70 lashes once a week. Cut off from his family in Egypt, the 52-year-old doctor was convicted for prescribing painkillers to a Saudi princess that led to her addiction.

An appeal court judge ruled that Amin will be beaten weekly until he has received 1,500 lashes - and then he'll spend another 14 years behind bars.

Talk about setting a precedent. I can't imagine any Saudi physician would be willing to prescribe narcotics after reading this.

It is common to find patients waiting for admission sitting in the hallways of emergency departments.

A new study suggests there is no harm in transferring them upstairs to the floor, where they can wait in the hallways there.

The sight of waiting patients on a medical floor would put pressure on the administration to open up rooms, and transfer the patient's care to the floor nurses. Predictably, they are resisting the idea:

But nurses and government regulators have resisted, citing safety issues, “as though the emergency department hallway is a safer environment,” he said in frustration.

This is a turf war more than anything else.

Lost is the fact that much of the wait for hospital beds is due to nurse staffing issues. It would be more effective for hospitals to hire nurses than to play this game of musical hallways.

Say a concierge doctor charges you a $2500 annual retainer fee. Sounds expensive, right?

But not after you break it down where the cost can be mere dollars per day, after savings from reduced wait times and improved access are considered:

Or is it just that giving up the daily Jamba juice or Pinkberry yogurt in exchange for personalized health care is just too much to ask of anyone?

And that's not counting the wave of lower-cost cash only practices which can be as little as $79 a month.

It's very real glimpse into primary care's future.

When one thinks about placebos, sugar pills come to mind.

As Shadowfax illustrates, it's can be so much more than that, ranging from IV fluids for flu-like symptoms to plain x-ray films for musculoskeletal pain.

A placebo can certainly be more vague than initially thought:

In the end, I don't really know what a placebo is. There's a no bright line that separates the "sham" treatments from the "real" ones, and consent is a variable which is inconstant in terms of patients' ability or need to explicitly understand and agree to the treatments.

Most patients feel better when they see the doctor "doing something" for them, which is why so many unnecessary tests get done.

Here's why.

These are very common injuries that present to the emergency department. Who better than plastic surgeon Ramona Bates to talk about treatment and suturing techniques?

Here are some responses to last week's NY Times op-ed suggesting that a comparative effectiveness institute be considered.

Most of the resistance comes from the fact that medicine is infinitely more complex and variable than the current tools of empirical data can resolve:

The number of variables in medical care (patient and treatment variability, co-morbid conditions) and degree of subjective interpretation (severity of illness) is far greater than in baseball.

That's true. No study can incorporate the myriad of patient conditions that doctors routinely face.

Costs of such an idea also present an obstacle:

More money for evidence-based research is not the answer and is quite an irresponsible request in these precarious economic times.

Probably goes a bit too far, as I don't think the suggestion was irresponsible at all.

I think basic comparative effectiveness needs to happen, if only to place more gravitas on medical evidence.

Without knowing whether treatment truly works, or if diagnostic tests are really necessary, the current trend of practice variation will continue to balloon health care spending.

Managing chronic pain is becoming increasingly difficult. As Dr. Rob observes, many primary care doctors simply don't prescribe narcotic medications.

Worse, pain specialists often won't either, preferring to focus on procedures and non-narcotic management:

What happens when, despite my best efforts, the person is still in significant pain? Most of the time I get to an impasse like this, I send the patient to a specialist. The job of the specialist is to take care of those cases that are too difficult for me to handle. But in the case of chronic pain, there is a problem: most of the pain specialists in our town don’t prescribe any narcotics. None at all. They offer procedures and non-narcotic medications, but won’t cross the line and give pain medications.

There are multiple reasons for this, including fear of DEA prosecution, risk of a "drug-seeking" patient population, and the fact that procedures for pain pay better.

But where does that leave the patient, as well as the primary care physician who's left to treat chronic pain without any consultant backup?

When government gets involved, unintended consequences often ensue. One example is the so-called "moral hazard," where people are insulated from the consequences of risk:

The person may behave differently from the way the person would behave if fully exposed to that risk. Here’s a familiar example: If you insulate people from the consequences of taking financial risks, they may behave recklessly and borrow or loan money for home mortgages which can’t be paid back.

See how moral hazards are rife in our health care system.

Studies have suggested that more doctors than ever do not recommend the profession to their children. With all the interference from insurance companies and government, doctors are frustrated and the future of the profession does not bode well.

Brian Carty recounts an encounter with a prospective medical student, and emphasizes that those considering this career better not do it for the money (via The Happy Hospitalist):

When I was applying to medical school, I remember how hurt and indignant I felt whenever anyone suggested that there were other desirable careers besides medicine. This is an obvious truth, but such comments were mainly meant to comfort people who weren’t accepted to medical school. However, in the 70s, it would never have occurred to anyone that medicine might not be a well paid career. I hope it occurs to people now.

Manoj Jain asks whether politics belong in the exam room in his recent Washington Post piece (via the WSJ Health Blog):

I have strong political opinions, but I am edgy about disclosing them to my patients for several reasons. For one, I'm in an authoritative position: When I talk about antibiotics, my patients listen and usually do as I advise. As a result, they might give inappropriate weight to my political pronouncements. For another, I fear that no matter how carefully I tread in these conversations, a disagreement could leave a dead zone in our relationship; that would be damaging because doctors and patients have to work as a team.

Some patients take political disagreements so personally that it may indeed damage the relationship. Most physicians I know won't talk politics with patients partly for this reason, but mostly because there's simply no time:

Another colleague, an orthopedic surgeon, also refuses to talk politics, but his reason was purely practical: "Who has the time to chitchat?" That's a good point. As a 2006 study showed, the average primary care visit is 17.4 minutes long and includes discussion of 6.5 topics. Often, I barely have time to spell out the potential side effects of my patients' medications. A political discussion should include more than sound bites.

3 1/2 hours, according to a study. After that, patient satisfaction scores plummet. I'm surprised the scores didn't drop sooner than that.

To help with patient satisfaction, hospitals are resorting to a time-tested marketing tactic. Underpromise and overdeliver:

Basically, the docs calculated the mean time it took to get through the ER for a given test or procedure — then added 20% when they told patients what to expect. In a standard patient satisfaction survey, all nine variables related to wait times improved after the ER adopted this policy (the improvement was statistically significant for five of the variables).

Some hospitals have signs up informing patients how long the wait is for certain tests. I don't know why this hadn't been thought of sooner.

Another general internist leaves The Happy Hospitalist's area, and there is difficulty finding a replacement. It's not news that this scenario is mirrored throughout the country.

He goes on to say that half of the health care dollars is spent by 5 percent of the population.

Generalists are needed to coordinate care, which will help rein in costs from this demographic subset. Not just a few, but "hundreds of thousands of generalists able to understand the big picture."

Here's what needs to be done:

If you want internal medicine to be a center point of patient access, you will have to make it fun again. Nobody who spends their entire high school, college and medical school career working their ass off will become the lowest paid, under appreciated, but most cost effective physicians. The docs we need the most of are rewarded the least. The docs who have the single greatest ability to pull back the unrelenting reigns of health care spending are leaving in droves.

Spending money to prop up the generalist foundation is the only solution I can see. Hopefully those in charge will come to that realization soon.

Theresa Chan is a hospitalist physician in rural California. When she started out, she had the ideal of "doing it all," which is the type of doctor that is needed the most:

When I arrived in Rural I was determined to do it all: see patients for primary care, admit them to the hospital, assist surgeries, deliver babies--everything . . . I did I&Ds, skin biopsies, colposcopies, IUD insertions and endometrial biopsies. I saw patients for 30-32 hours per week, slugged through charts and paperwork another 10 hours per week, and took call every Thursday and one weekend per month.

Then reality hit, and she was forced to deal with the harsh truths of primary care medicine. Some were unique to her situation, others could felt by generalists nationwide.

Economic factors were noted to play a role, as the compensation was not commensurate with the amount of work she did:

Now, I'm sure you can argue that $95,000 in direct salary is twice the national average for a two-person family, so surely I can't cry poor--and you'd be right. However, I didn't say my salary wasn't enough for me to keep body and soul together . . . Given the rapid rise in property prices in California between 2001-2004, including Rural County, I could not have bought a house on $95,000 of direct income a year . . .

Primary care is where the best and the brightest physicians are needed the most. Any hope of health care reform depends on the availability of generalist access.

If dedicated doctors like Dr. Chan is leaving the field for greener hospitalist pastures, you can be sure that the same decision is being made by countless others across the country.

It isn't even close.

UptoDate is geared towards everyday clinical use, and I can obtain succinct, evidence-based answers in a fraction of the time when compared to PubMed.

If only more information officers thought like John Halamka. He rails against complexity, and I completely agree:

In the world of IT, simplicity is often more reliable, more secure, and more usable. Whenever I'm tempted to add complexity to address the needs of a few customers, I remind myself that Less is More.

Many electronic record systems are needlessly bloated with rarely-used features. This steepens the learning curve, and makes finding and removing the problems more difficult.

Give me simplicity any day. Something that works as close to 100 percent of the time as possible, is intuitive, easy to learn, and makes the physician's job easier.

If doing away with features is needed, so be it.

Emergiblog hosts the weekly best of the medical blogosphere.

That's never a sustainable business model (via Jay Parkinson), especially in primary care. This will lead to more hospitals buying cash-strapped practices, and using them as "loss leaders" to drive traffic to the hospital.

I don't see how small, independent practices can survive without hospital help going forward.

. . . if all goes according to the polls next week.

Cardiologist DrRich argues this isn't necessarily a bad thing, since it will open up discussion on how we should limit health care to provide this "right."

Here's the dissonance that the public will have to face, as DrRich so eloquently states:

To reiterate the fundamental problem: 1) In America we believe that it is wrong to limit healthcare in any way, that everyone is entitled to the very best healthcare, that any bit of healthcare that offers even a small potential of benefit should be provided, and that death itself is merely a manifestation of insufficient research (or actionable incompetence, or systematic discrimination against the unwealthy, or corporate greed). 2) But against that closely held belief, we must balance the unremitting law of economics which tells us that there is simply not enough money in the known universe to buy all the healthcare that might potentially offer some small amount of benefit to every person. Healthcare spending has to be limited, or it will become a fiscal black hole.*

Opening the dialogue on how care will be rationed is welcomed, as this will be a necessary issue to tackle in the coming years. Declaring health care a right may be the impetus to start discussing these difficult decisions.

Maggie Mahar, responding to a recent WSJ editorial, tries to soften the blow and calm fears of a government takeover of health care.

Having multiple physicians care for patients is a fact of life, especially as more doctors become sub-specialized.

Medical errors can arise during these hand-offs. Here are some tips that can reduce errors and prevent fumbles. It comes down to clear communication and not relying on third parties to pass on the information.

Boston's BI-Deaconess Hospital is leading the way in transparency, with unprecedented openness in dealing with medical errors. Hospital CEO Paul Levy regularly blogs about sensitive issues.

The Boston Globe runs a piece about some adversity surrounding their openness, but I agree that over time the hospital will be judged fairly and lauded for their honesty.

Dr. Val and Charlie Baker chime in with their takes.

Costs can exceed $30,000 per physician, with the majority of savings going to the government and health insurers.

Here's the incentive (via Mary Johnson) doctors have to make the digital move: "You’ve got to cut costs, see more patients or suck it up."

Great deal. Here's my take on the issue.

Only 6 percent of physicians currently e-prescribe, and Medicare is going to start bringing out the stick.

One reason for a low rate of adoption is that controlled substances cannot be prescribed electronically, forcing physicians to maintain two systems.

Other issues are outside the physician's control. One is the difficulty in implementing specific formularies within the e-prescribe construct. The other is that many small pharmacies are not equipped to handle e-prescriptions.

Not the norm in the hospitals where I've worked, but I can see where they might come in handy.

I typically use Google or a number of online tools to identify pills, using the numbers on the pills as keywords.

Do not reflexively refer the patient to a psychiatrist, that's the take home point.

Great advice from Maria, who is a psychiatrist herself:

That hasty referral sends the message that (1) it’s not okay to cry, (2) I don’t want to see you cry (or I can’t tolerate seeing you cry), and (3) there must be something wrong with you since you are crying. (”Not only do you have Medical Condition X, but you might be mentally ill, too!”)

Here's what you should do instead.

This is an unbelievable story. A South African-born emergency physician was denied Canadian citizenship. The reason is stunning:

Dr. Stanley Muwanguzi is frustrated with being in limbo while Citizenship and Immigration Canada officials review his application, which was denied in June 2006 on the grounds his cerebral palsy-stricken daughter would constitute a burden on the health-care system.

He's thinking about moving to the United States instead, as medical recruiters promised that his immigration papers would be fast-tracked:

Muwanguzi said medical recruiters in the U.S. have told him he would be fast-tracked to receive a green card within two years because that country is also in desperate need of physicians.

Puzzling move by a country that could use a few extra doctors to staff their emergency departments.

More physicians are using the microblog service Twitter. This past weekend, two medical conferences were updated by the minute from plugged in doctors.

Clinical Cases and Images' Ves Dimov and emergency resident Graham Walker brought us the NEJM's Horizons Conference, where they provided their input and expertise to influence the NEJM in their Web 2.0 initiatives.

Rural hospitalist Theresa Chan was also prolific in updating the Management of the Hospitalized Patient conference in San Francisco, sharing valuable tips from the lectures.

For doctors who weren't able to attend, this was a fascinating opportunity to stay connected and provide instant feedback on the proceedings. Cutting edge indeed.

This rural physician feels that today's generalists spend most of their time managing chronic disease, like hypertension, diabetes and heart disease, rather than diagnosing new disease. Which isn't necessarily a bad thing, but not what it used to be:

Managing chronic illnesses can be very meaningful and satisfying, but it isn’t quite what I imagined I would be doing to this extent. But it is one of the reasons we need to hone our skills as physicians; it is no longer enough to be a good diagnostician when almost every patient we see in a given day already has a diagnosis established. Our challenge is to help them manage that diagnosis. That means we need to practice motivational interviewing for our patients with lifestyle-inflicted diseases, serve as our patients’ medical home in a fragmented health care system and be a voice of reason in an era of information overload.

Not sure that's true, since I certainly find my share of new diagnoses over the course of a day. A lot can be uncovered by ordering the recommended USPSTF screening tests.

It's true however that if you really want to see new, untreated diseases in a patient, you'd have to practice in a more remote area.

What can doctors learn from horsemanship?

Major media loves to publicize exceedingly rare complications of vaccines. With the flu shot season in full swing, a case of a man contracting Guillan-Barre syndrome is making headlines. This is literally a one in a million complication, but you wouldn't know that from the alarmist headline.

The flu shot vaccination rate is still too low, and Sam Solomon urges some perspective:

Did CBC News act responsibly by publicizing the story of one man whose case, according to a neurologist, is not representative and not making sufficiently clear the calculations and balancing of risks that have gone into developing public health and vaccination recommendations over the years? There's no denying the public has a right to know what is going on, but at some point the editorial decision-making process has to draw a line about what is newsworthy and what is sensationalist.

Vaccines are safe. Don't be fooled by the attention-grabbing headlines.

Recent news have focused on the staph infections in Kellen Winslow and Payton Manning, as well as the unidentified infection of Tom Brady's knee.

Are football players more prone to contracting MRSA?

Like athletes in other contact sports, football players are prone to staph infections because of their sport’s skin-on-skin contact, the frequency of cuts and the warm, moist conditions in locker rooms, which encourage the growth of bacteria. Because they are regulars in surgery wards, athletes are susceptible to infections there, too.

NFL football players receive the best care possible. The fact that infections can still complicate their post-op courses means that no one should take any surgical procedure for granted.

Update:
Surgeon Jeffrey Parks comments further on the MRSA epidemic in NFL players.

LapCorp stops selling the controversial ovarian cancer screening test, after being warned by the FDA:

The case has raised questions about the degree to which the F.D.A. can or should regulate diagnostic tests.

Doctors have long sought a test that could detect ovarian cancer early, when the condition would be more treatable. But some experts had said that LabCorp’s test, called OvaSure, had not been proved to work.

Screening for ovarian cancer has not been shown to save lives, and results in unnecessary procedures from false positives.

Having the FDA regulate diagnostic tests isn't a bad idea. Many companies unscrupulously profit from the public's "more screening is better medicine" mentality, especially with the advent of genetic screening tests.

Regulating tests can reduce unproven screening, which will cut down on the number of false positives leading to unnecessary procedures.

Here's a video game for the Wii.



It's not far off from how future surgeons may be taught. (via NHS Blog Doctor)

With a likely Democratic-controlled government arriving soon, universal coverage will be the hot topic. Politicians better remember that physician access will be the key to making it work, or else you'll have a Massachusetts situation with newly insured patients flooding the emergency room.

Doing what Pennsylvania Governor Ed Rendell is doing is precisely not what to do. M-Care is the state's supplemental insurance program that helps fight the costs of malpractice premiums. To push his political agenda, the Governor is withholding funds until doctors buy into his version of universal care:

Pennsylvania's physicians are willing to provide health care for those who can't afford it. More than 90% of us accept Medicaid despite reimbursements that are obscenely low and have not been raised since 1989. But what I, and other doctors, object to is being extorted to fund the governor's sociopolitical agenda.

I hope the legislature resolves this unseemly debacle appropriately by directing M-Care to start spending its funds on the program's stated purpose (cutting the cost of liability insurance) before year's end.

But in the meantime, if you are a woman with a high-risk pregnancy who is unable to find an obstetrician in the rural areas between Philadelphia and Pittsburgh, or if you can't find a neurosurgeon on trauma call in the two-hour drive from Pittsburgh to Erie, call Mr. Rendell. He can tell you about his plans to "cover all Pennsylvanians."

Doctors will simply leave the state if they are coerced into reform that is not favorable.

Like it or not, we are the backbone of any reform plan to cover everyone. If we are left out of the political process, any proposed plan is doomed to fail.

A radiologist flushes his lover's head in the toilet. Twice.

The Gone Wild series continues.

. . . to Shadowfax, and don't be one of the 10 percent.

Not a very smart move by this employee who called in sick. Don't go advertising on Facebook that you got trashed instead.

A BMJ study is catching the eye of mainstream media (or is this a case of "gotcha" journalism?), with headlines blaring that half of American doctors regularly prescribe placebos to patients. Those unethical bastards:

The most common placebos the American doctors reported using were headache pills and vitamins, but a significant number also reported prescribing antibiotics and sedatives. Although these drugs, contrary to the usual definition of placebos, are not inert, doctors reported using them for their effect on patients’ psyches, not their bodies.

In most cases, doctors who recommended placebos described them to patients as “a medicine not typically used for your condition but might benefit you,” the survey found. Only 5 percent described the treatment to patients as “a placebo.”

Couple of points.

# Antibiotics and sedatives are horrible choices for placebo medication. They have very real risks and side effects, such as increasing the incidence of drug resistance bacteria with the former and falls with the latter.

# Telling your patients that you're giving a placebo defeats the whole purpose of prescribing one.

# Many alternative medical therapies are suspected to have a strong placebo component to their supposed effectiveness.

# Placebos have been shown to work in cases of depression, hypertension and pain. However, ethically incorporating the power of the placebo effect in everyday medical practice remains a challenge.

Maggie Mahar takes the NY Times editorial staff to task on Medicare's never events. The piece stated that doctors and hospitals need to work "harder" to stop errors.

As if doctors spend all day drinking and cavorting.

Often times, medical errors occur because doctors have too much on their plate:

Let me suggest that telling staff to “work harder” is not the answer to hospital errors. Most often, patients are harmed because too many people are doing too many tasks under too much pressure—with too little time to communicate properly with each other.

Medicare's no-pay list, and especially its proposed expansion to include hospital infection, falls and delirium, is fraught with unintended consequences. Those so eager to point the finger at physicians should be careful of what they wish for.

Matthew Mintz is disturbed by a letter from CVS pharmacy, making overt recommendations of a brand name Merck diabetes drug:

Though today it was only a letter promoting a drug attached to a patient who might potentially need it, what's next? Will I be receiving promotional calls from my local CVS pharmacy which seems like a professional to professional communication, but is really a disguised sales pitch? Will the retail pharmacist get a pop-up message when a patient is refilling a certain medication to ask their doctor to prescribe another? We are a free market society, and drug companies have a right to market their products, but the letter I received today is just plain wrong.

Pharmacies recommending switching to generic medications is fine, but it is to the patient's detriment to start promoting expensive brand name medications.

Health IT guru John Halamka writes a letter to the future President. It's advice well worth listening to. I like the paragraph relating to penalizing primary care doctors for failing to adopt electronic records:

We need to be careful, though, about what actions the government takes. A recent Congressional Budget Office report concluded that imposing penalties for failing to adopt health IT would be more cost effective than providing financial incentives. Primary-care physicians in the U.S. are already struggling with high costs and low reimbursement. Asking them to comply with another unfunded mandate based on penalties rather than incentives won't solve the problem, because it doesn't acknowledge the underlying economic misalignment that has discouraged adoption in the first place. The result won't be more EHRs; it will be fewer medical students choosing primary-care careers, which will fuel even greater increases in health-care costs.

Bravo. I hope someone's listening.

Not only are waits to get a doctor's appointment long, but once you're there, expect to spend more hours waiting.

The reason boils down to this: too many patients in too few time slots. As physician payment decreases, doctors respond by seeing more patients. It's the fallacy of cutting physician pay in a fee-for-service world.

Doctors can either be on time, or spend time with you. You cannot have both. If you value being on time, choose a punctual doctor, but expect efficient visits. If longer appointments are your preference, expect delays.

CNN's Elizabeth Cohen offers more tips to patients, such as seeing someone else.

However, that's no incentive for doctors to change. As long as there continues to be a physician shortage and pent-up demand, for every patient that leaves, 10 more are more than happy to take their place.

With Baby Boomers entering Medicare age, demand will only increase. Expect the situation to get worse.

If you're a doctor, access is valuable currency. If handled correctly, it is the most powerful marketing tool for your practice.

Malpractice? High physician salaries? Aging of the population?

All partly responsible, but none more so than advancing medical technology combined with low productivity.

Maggie Mahar writes that new technology, such as MRIs, are being used inefficiently due to the proliferation of free-standing outpatient facilities:

The problem is this: rather than collaborating to share new technology, hospitals and outpatient centers all invest in the same equipment as they vie for well-insured patients. As a result, “costs in outpatient settings are higher” than they need be, and higher than in many hospitals “because of subscale operation of facilities.” Ginsburg explains: “In contrast to a hospital where CT equipment is being used for 20–30 scans per day, freestanding outpatient facilities,” which charge “very high prices” and enjoy “lower overhead” can “earn a profit at 4–8 scans per day.”

Re-aligning the financial incentives would go a long way to rectifying the problem. Not paying for excess procedures will prevent these centers from being built, perhaps improving the efficiency and reducing waste.

Another area touched upon are high American physician salaries, a favorite area that many health policy wonks would salivate to cut:

Physician compensation in the United States is 6.6 times per capita GDP for specialists and 4.2 times for primary care physicians. By contrast, in the average OECD country, specialists 4 percent of GDP per capita, while primary care doctors take home 3.2 percent.

Although Maggie does fairly point out that exorbitant medical school costs somewhat justifies the high pay.

I'll go one step further, and say that comparing American physician salaries with foreign doctors is completely irrelevant.

In addition to the medical school cost difference, other countries do not have the malpractice costs that physicians face in the United States. Furthermore, when you compare the average CEO and attorney salary with those abroad, there is likely to be a similar disparity. Why aren't more people clamoring to cut lawyer's fees?

American physician salaries are what they are because of factors unique to this country. It is impossible, and irrelevant, to compare the numbers with those abroad.

Massachusetts is a nice lab to see the effects of an Obama health plan. The proposals are fairly similar, with the exception that Obama does not mandate individuals to obtain insurance.

One consequence is a marked rise in emergency care, due to lack of primary care access.

Now a second shows that people still can't afford health care, despite 97 percent of the state being covered with some sort of insurance:

Although far more Massachusetts residents have health insurance coverage than residents nationwide, a significant portion of Bay Staters are still struggling to pay for needed healthcare, a new survey shows.

Some are postponing treatments, and others are not filling prescriptions, because of high costs or an inability to pay bills from earlier procedures, according to the survey by The Boston Globe and the Blue Cross Blue Shield of Massachusetts Foundation.

Promising universal coverage scores easy political points, and helps one get elected, but it really does nothing to solve our health care woes.

The One Slide Project.



(via Our Own System)

Health policy wonks need to read medical blogs. Unexpected results from simplistic pay for performance measures were predicted early on by several medical bloggers.

Consider the fact that hospitals will have little incentive to treat certain populations under Medicare's pay for performance system:

That means that hospitals serving large groups of the elderly, women, poor, uninsured, or African-American patients might have problems competing with institutions whose patients are younger, wealthy, insured, and white.

And you wonder why more hospitals are moving to the suburbs.

Sure, Charlie Baker has a vested interest not to have a Medicare for all or single-payer system adopted. But what he says makes sense, and I wonder myself why some physicians (*cough*PNHP*cough*) have such blind faith that the government won't take a hatchet to the medical profession in the name of saving money.

Governments have consistently shown their stripes in these times of budget shortfalls, repeatedly cutting physician and hospital payments despite the fact that this will obviously lead to higher costs down the road:

In Massachusetts, the state is not only cutting Medicaid payments prospectively - it’s cutting Medicaid payments for some providers retrospectively - simply choosing not to make payments to them they had planned on and expected.

I must say, each time this happens, I can’t help but wonder if the hospital operators and physician leaders who think a single payer like Medicare For All is a good idea ever stop to think about how these agencies deal with their financial problems. When they have a problem, they unilaterally whack their provider community hard - in ways private sector payers would never consider.

If there was only one payer, we will be slaves to their arbitrary payment cuts. There will be no recourse. We can't "drop" our only payer, like we can now with Medicare and Medicaid.

And tell me how is that better than what we have now.

There's no more powerful tool, as PookieMD writes to great effect. Why aren't they used more frequently?

Frightening.



(via Dr. Anonymous)

MRI scanners are infested with bacteria, and apparently cleaning them is somewhat of a conundrum:

The magnets and the pads on the table can harbor MRSA and need to be cleaned. But cleaning crews are not permitted to go into the imaging room unless technologists supervise them at all times. Since the cleaning crew usually comes late at night after the technologists have gone home, the MRI rooms are rarely if ever cleaned.

Why isn't it a good idea to clean the room unsupervised? Well, it can be dangerous if you don't know what you're doing:

For example, if they bring in anything metal (like a screw driver) it will be drawn into the magnet at over 60 miles an hour . . . Also if a new cleaning person has a pacemaker or aneurysm clip and enters the room he could be killed.

Wait, the news gets worse. There are no sinks in MRI rooms, given the challenge of running pipes into an MRI suite. And don't even think about mobile MRIs:

Mobile MRIs don't even have running water and technologists rarely wash their hands between patients. They keep spreading these bacteria. They're often too busy and infection control gets overlooked. The price of an MRI is coming down so they need to scan more patients in less time, leaving no time for proper infection control. Technologists feel they could be fired if they are too slow at turning around the MRI room for the next patient.

Yikes. Something to think about before you request that MRI for back pain.

The following is a reader take by Edwin Leap.

While I was driving my rental car a few days ago in another city, a man passed me on his chopper. He was covered in tattoos and his long hair was blowing wildly in the wind. He looked the very image of freedom, of unrestricted energy. Snug in my safe (boring) Chevy Cavalier, on the way to a meeting, with Mozart on the radio, I didn’t give him another thought. Then I realized something. Practicing medicine has changed me.

Looking back on my youth, I remember a time when motorcycles weren’t as common as now and when tattoos were perceived as things for the fringe of society. In my sheltered, judgmental youth, I would have felt a little afraid of that man. Now, years later, I see the world differently.

I know that man. I’ve treated him over and over. I’ve closed his cuts, listened to his story, given him medicine, tried to help his depression, examined the road-rash from his wrecks, opened his chest, felt his blood, pronounced him dead, remembered him and written about him. Sometimes he was a scoundrel; mostly he was a good guy having a tough time.

I know that man because I know so many men and women. And there are some reasonable generalities, since every human being shares features. Medical school is largely about identifying those commonalities, so that the unique differences of disease and injury can be recognized. We share the same sorts of hearts, pumping similar sorts of blood to assorted analogous organs, all requiring oxygen, carbohydrates and protein.

Our arms and legs are usually arranged in a manner similar to one another and our heads perch solidly on top of our torsos as they should. (Any other arrangement would make motorcycle riding decidedly more hazardous). We humans are remarkably alike, whether you subscribe to a Darwinian origin for man, or the common mind and plan of the Creator.

But there’s more. We’re alike in the wonders of our imaginations and the amazing capacity of our brains. We are similar to one another in our creativity, our sense of wonder, our desire to explore, our deep need for physical affection and emotional connection. We’re alike in our love of families and our desire to be healthy and whole. Subtle variations exist, but these are generally shared traits.

We resemble one another in more ways yet. We’re alike in our vulnerability. Our bones break. We bleed when we are wounded. Our hearts stop with 100% consistency in the end. And beyond the merely physical, we’re alike in our inner brokenness. We’re similar in our collective tendency to view ourselves as unacceptable; to feel ourselves unworthy. We share the wounds of childhood and adulthood. We share a need to be whole, somehow, someday…some way.

The great thing about medicine is that it has shown me how very close we are to one another in so many ways. And it has proven to me that there are good people, and people much like me, with every possible appearance. They are investors with suits; they are bikers in leather. They are teen girls in sun-dresses and sandals, and dying old men in cover-alls. The good folks of this nation, and this earth, have no uniform to aid their identification. They lurk in the worst of clothes and best. They hide themselves in every type of career and every imaginable hobby, waiting for the chance to show us their humanity, waiting for the opportunity to show us love, or to receive it.

This is probably a relevant time to remember that. Economic crisis looms, cultures clash within our very borders and the election of a new president promises frustration on the side of the losers. We all want someone to blame; we all want someone to pay, as if we could calculate compensation for such complexities. Many want to punish banks or a political party. They want to punish the rich, or the old, the right or the left.

But wait! Good people are riding choppers past your car! They’re working in landfills. They’re running multi-national corporations making millions of dollars; they’re working at a factory making lots less. They’re in prison. They’re in government. The good people of this world are all around, often unseen.

Ultimately, it won’t be banks or governments, taxes or policies that pull us through the future struggles that loom. It will be the strength of our sameness. I only hope we can recognize that fact before it’s too late.

Edwin Leap is an emergency physician who blogs at edwinleap.com.

Nurses suffer from low morale in part because they do many tasks outside their core training, such as answering telephones, changing bed linens, transporting patients for lab tests and drawing blood.

The same can be said for primary care physicians who spend much of their time filling out forms, obtaining pre-authorizations, and navigating through the bureaucratic maze of health insurer paperwork.

In many cases, no. Pathologist Brian Jackson brings up some good points on unnecessary testing. He cites PSA test screening for prostate cancer. By itself, the test is $20, but false positives can lead to an unnecessary $1,000 prostate biopsy or $10,000 prostatectomy.



Currently, both financial and legal incentives propel doctors to order more tests, whether they are needed or not. Removing both these drivers will be the most effective way to clamp down on unnecessary testing.

Surgeons use markers to identify the right body part for procedures. Unfortunately, they care become contaminated with bacteria which can lead to surgical site infections.

Enter the Sharpie: "As it turns out, the ink used in a Sharpie pen has an alcohol base, making it an unexpected germ fighter."

Who knew? The Sharpie is probably also many times cheaper than the single-use "sterile" pen used commonly on ORs.

The economy is causing patients to stretch out, or cut, their prescription medications. This has significant potential to further raise health care costs down the road:

If enough people try to save money by forgoing drugs, controllable conditions could escalate into major medical problems. That could eventually raise the nation’s total health care bill and lower the nation’s standard of living.

Many of the life-saving cardiac and diabetes medications are available generically, and many pharmacies have these drugs at a $4 per month price point.

There's little reason to stay on brand name medications in the majority of cases, so patients would be well advised to undergo a medication review with their physician to maximize generic drug use.

Interesting take over at the technology blog GigaOM (via Healthcare Economist).

Rapidly advancing technology is bringing sophisticated diagnostic tests, like genetic screening, to the masses. Many are undergoing these studies, without the benefit of rigorous data to ensure that there is a benefit.

We already know that unproven testing can lead to patient harm, in the form of false positives, unnecessary invasive testing, and patient anxiety. In addition, it can lead to a significant, possibly unneeded health care burden:

Thanks to technology, such diagnostics are now within the reach of consumers. As more people test themselves, doctors and insurers may face the additional burden of just-in-case surgery and a “previvor” mentality. So, will technology cure health care, or kill it? . . .

. . . Will widespread diagnostics increase the burden on healthcare? Somewhere between 10 and 50 percent of autopsies reveal diseases other than the one that killed the patient. If consumers test themselves, then tell their doctors, the medical system could wind up treating 50 percent more diseases than it does today — even those that wouldn’t have killed the patient.

No matter how perfectly a surgery seems to go, the recovery process is still heavily dependent on the patient. Surgeon Jeffrey Parks talks about how frustrating this situation can be:

No matter what you do, no matter how textbook the operation, no matter how perfectly you manage the recovery phase, sometimes the patient fails to progress. You bang your head against the wall searching for an underlying reason. But the explanation is quite simple. A patient needs to want to get well. They have to want it with every ounce of their being. It doesn't matter how hard you work or how many tests you order. Once a patient loses the heart for the good fight, the ultimate outcome is inevitable.

Catchy headline, and of course, mainstream press is again blaming the medical profession.

Getting billed for $162 and not seeing a physician looks bad on the surface, but I haven't read any reports delving deeper into the reasons why there was 19-hour wait in the first place.

Luckily, Doug Farrago is here to explain why.

Over $700 billion is wasted on unnecessary medical care yearly. This Boston Globe op-ed gives some eye-opening examples of where to start trimming the fat:

# Wide variations in patterns of care - why, for instance, surgery for coronary artery bypass or hip replacement is performed more frequently in one area of the country than another. Potential savings: $600 billion a year.

# Medical mistakes such as wrong-side surgery, medication errors, and preventable hospital-acquired infections. Potential savings: $52.2 billion a year.

# The overuse of hospital emergency departments for nonemergencies. Potential savings: $21.4 billion a year.

# The underuse of drugs and other therapies to manage chronic conditions such as high blood pressure, diabetes, and asthma, leading to acute conditions (asthma attacks, insulin shock) and hospitalization. Potential savings: $5.5 billion a year.

# The overuse of antibiotics for viral infections (ear infections, sore throats, and the common cold). Potential savings: $1.1 billion a year.

Many of these issues can be resolved by reforming how doctors are paid. Remove the incentives to do more, see more, and treat more. Reward for healthy outcomes and for providing primary care physician access which can preempt expensive emergency department visits.

Sounds good, but it doesn't really address our health care needs, as the financial incentives continue to greatly favor specialists.

More medical students simply means further skewing the physician work force towards specialty care.

Instead of expanding or building new schools, I like the idea of offering scholarships for full tuition instead, making medical education free for those who choose primary care as a career.

So says Harvard Pilgrim's Charlie Baker. And in related news, Medicare for all is becoming an increasingly likely possibility.

The American Board of Internal Medicine warns of physicians "certified" by these scam boards.

Like sports stadiums, universities are auctioning off lucrative naming rights for their medical schools. It's big money, as the University of Minnesota is seeking $150 million for the honor of naming their medical school.

For now, it's limited to wealthy donors. But how soon will it be before corporations make an offer universities can't refuse?

An ACP reporter attends a seminar that goes deep into the business side of medicine, and doesn't like what she sees:

The speaker (a lawyer) started off by talking about the impending primary care shortage. Which seems to me like an argument against spa medicine, since we might need those few docs who are left for real clinical care, but I suppose it's also a market opportunity.

With margins squeezed, generalist doctors are ripe for revenue-generating sales pitches. Instead of hyping up unproven, cash-only gimmicks, perhaps a better solution would be to improve payment for what's really needed: real, primary care medicine.

The difference in quality of American medical schools seems to be negligible. Students from every medical school match into both competitive and non-competitive residencies, and perform similarly in test scores:

First, consider performance on the licensing exams. All universities, on average, have a 95% pass rate for their students. That also means that there is, on average, a 5% failure rate. Both Harvard and Drexel each have students perform at the top of the bell curve as well as those who fail outright. While there are differences in the average score, your performance on the test is based solely upon your own preparation, and not any magical instruction given by the school.

Knowing this, does it really matter where you graduated from?

(via Street Anatomy)

A disturbing trend that often goes unreported. See it to believe it.



(via The Medical Quack)

It's a sign of kidney failure and a signal that the end may be near: "When a patient suddenly stops making urine and their kidneys are shutting down…frequently the story won’t have a happy ending."

Solving some of medicine's problems requires thinking outside the health care box. Like borrowing bar codes from the grocery store, or checklists from airline pilots.

We need to do the same for electronic records, which are stuck with archaic, 1990s programming technology. Take the user interface of Google, mix in the social networking tools of Facebook, and allow instant collaboration via Twitter.

Now that sounds like something I would use.

Michael Lewis' Moneyball is an excellent book, and I regularly use its baseball insight when I play historical fantasy baseball over at Diamond Mind Online.

A NY Times op-ed written by the primary Moneyball disciple Billy Beane, along with Newt Gingrich and John Kerry, wants medicine to endorse more objective data when making clinical decisions.

They're essentially proposing a comparative effectiveness institute, where a national body can make empirical recommendations of what works and what doesn't, based on data from studies.

I'm in agreement with the concept. However, my biggest concern is how patients will accept it. With the mentality of "more medicine is better care" so entrenched in the American patient, how will they accept it when an MRI for back pain, or an angioplasty for stable coronary artery disease is denied?

Imagine the outcry when the latest cancer therapy gets denied.

Embracing the numbers is nice, but a significant effort to educate the public on the ramifications of evidence-based medicine is equally important.