There are some questions in health care that can’t be answered with a randomized controlled trial. We can’t randomize babies to inhale secondary tobacco smoke or not to test its health effects. We can’t randomize people to a different number of hours sitting the ER before receiving antibiotics after the decision is made that the patient has a bacterial infection requiring antibiotics. There are some questions where the best available ...

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I have written about both issues before: freestanding ERs and retail clinics. Two recent studies continue to show how useless they both are in helping create a better more efficient health care system. The freestanding ER study  examined the number of these facilities and population characteristics where they locate. They identified 360 freestanding ERs, mostly in Texas, Ohio, and Colorado. This will come as no surprise; they were located in ...

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Hospitalists, doctors who only see patients in the hospital, almost always in a shift work model, are the fastest growing “specialty” in medicine, from nothing about 15 years ago to about 50,000 today. There were some studies that I won’t review much here that showed some benefits from hospitalists compared to “usual care” in highly controlled environments, outcomes such as a 0.4 per day decrease in length of stay with ...

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Our national useless dialogue on the future of health care in the U.S. continues. Trumpcare has a long way to go before it potentially becomes law, so no one knows what it will finally look like. Obamacare is in a death spiral anyway. So the existing financing system will change no matter what. But once again the two-party scream-at-each-other system is only talking about changes in health care financing. On one side, ...

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In our recent paper criticizing how industrial quality improvement has been misapplied to primary care, we didn’t just complain, we made suggestions for a better way forward. This was under the assumption that regulators and payers will continue to insist on some kind of numeric reporting of outcomes by physicians or practices whether physicians like it or not, or whether it’s really useful and fair or ...

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This post is based on a "friend of a friend" situation. Important details have been changed to protect anonymity, but not the basic realities I want to discuss. A 49-year old man was diagnosed with a rare form of lung cancer about a year and a half ago. This sad situation is compounded by the fact that he was in a stable marriage with a wife and two children, ages 10 ...

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I have written before about predictions of the actual costs of Obamacare and the probable death spiral of increasing costs and decreasing participants. Several recent reports have brought more clarity to the cost realities. Recently regulators across the country approved rate hike requests by Obamacare insurance companies even greater than they originally asked for. For example, Pennsylvania regulators approved rate hikes of 33 percent, which was ...

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From the mid- to late-2000s, lots of pundits got into the business of shoving electronic medical records (EMRs) down doctors’ throats. There were a few incentives from the feds to help with the upfront costs, but it was a pittance of what it really costed hospitals and physician practices. And there was no consideration made for the ongoing costs of EMRs, except for cuts in already skimpy Medicare and Medicaid ...

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Prescription opioid abuse is on the political radar. “Painkillers” are a recognized cause of thousands of deaths a year. But what to do about it? A FDA panel recently recommended mandatory training for physicians who prescribe opioids. Congress passed a bill calling for more education, presumably physicians as a prime target. We’ve actually been down this road before, but possibly not how you think. The politicians and pundits used to complain ...

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All of us who care for the poor, the illiterate, the poorly educated, the immigrant, the frail, and the abused know this: caring for them involves many challenges that aren’t picked up by Medicare computers or big data. Simplistic calculations about quality metrics such as hospital readmission rates have been way off the mark at capturing the complexities of caring for these patients. A recent study from researchers in Boston ...

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