American health care has become a gigantic game board with players of all sorts strategizing to win. Winning, of course, means getting more money from payers: government or private. It turns out this medical marketplace game is not all that new. It's just become wilier, as I have shared in a couple of posts over the summer. An obituary last week for Dr. Rashi Fein, an influential economist with a progressive stripe ...

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She was sick.  Not sick like a high fever, body aches and a runny nose.  Sick like she had spent the last half a decade in nursing homes as most of her internal organs failed.  There was oxygen, and dialysis, and a colostomy.  She propelled herself vigorously through the crowded halls in the custodial wing of the nursing home, her wheelchair a natural extension of her body thoroughly unhampered by ...

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She was nearing the end of a long and interesting life. Her birth was announced on the party line in her rural community’s first telephone system. Her death, which would come soon, would be shared on Facebook and via cell phone. She had graduated with a degree in home economics from the University of Minnesota in 1938 and had worked for a meat packing company during and after World War ...

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Mrs. D was my last patient. I retired several months ago, and for some time prior I informed my patients so as to give them time to decide where they would like their follow-up care. Mrs. D was an elderly lady who I first met in the ER several years prior after a fall resulting in a displaced ankle fracture. She was pleasant and alert, understanding everything I was explaining after ...

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We were intimate. As intimate as a doctor and patient can become.  He had long outlived his wife and there were no children, no family, just friends.  When he first came to me he was lively and active, but the years took their toll.  Our visits became more regular.  Every six months.  Then every three. His memory started to slip.  Occasionally he would look at me suspiciously when something went wrong.  His ...

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As every physician already knows full well, health care services delivered to the home rather than in an institutional setting are increasing, a trend destined to expand even faster in the decades ahead. This shift is inevitable, thanks to our rapidly growing elderly population and the corresponding prevalence of chronic illness, along with the nationwide push for higher quality care at lower cost and dramatic advances in medical technology such as ...

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Just a few years ago it seemed that advocates for health care transparency had scored a big victory. The Centers for Medicare & Medicaid Services (CMS) announced that they would rate nursing homes by awarding five stars to the best and fewer stars to lower-quality facilities. Families searching for care for loved ones would have access to a familiar rating system to help them make choices. After all, star ratings for ...

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Sometimes my day is like a book.  The first chapter may begin in the darkness of a self imposed corner as a phone call is made.  A voice, full with the thickness of slumber, answers unexpectedly. "I think today is the day." No matter how many years I have been discussing death I still find myself using poor euphemisms.  The bane of medical school teaching, I often struggle with the directness.  "Your mother ...

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The electronic medical record that my office uses features a clinical protocol button that we are encouraged to click during patient visits to remind us about potentially indicated preventive services, such as obesity and tobacco counseling and cancer screenings. I once tried it out while seeing a 90-year-old with four chronic health problems. The computer suggested breast cancer, colorectal cancer, and cervical cancer screenings: three totally inappropriate tests for the ...

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"If a tree falls in a forest and no one is around to hear it, does it make a sound?" Chances are that many of you have duked this out with your college roommates back in the day, but how about this one? “If a doctor and a patient make an advance care plan, but when an emergency happens, nobody can find a copy of it, the proxy doesn't know what's ...

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