Tag Archives: medicine

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Flu Update: The H1N1 (Swine Flu) is upon us!

I was stopped by a friend this morning who was concerned about the swine flu because he watched a 60 Minutes special last night about a teenager who died of the swine flu.  The special went into detail about this poor teenager’s suffering and death (or so I was told–I didn’t see the special).

It is time to STOP the presses!  The press/media is making people panic.

The facts:

  • If you have fever, cough, body aches, and/or headache, you have the flu–it is widespread and epidemic
  • 55,781 confirmed cases in U.S. & 1,081 deaths=mortality rate=1.9% NOW these stats are WAY off because those are the confirmed cases meaning cases that have been tested.  There are probably double that many of cases that were tested and were false negatives (had the flu but test was wrong–30-50% of the time!).  There are probably 10 times (at a minimum) more cases of the flu so probable cases of the flu in U.S. likely 500,000 or more so that means the mortality rate is far less than 1%.
  • The problem–those who are dieing are young and healthy.  Regular flu kills 30,000 people per year but they are very old or very young people.  New pandemic flu strains attack the people in their prime.  This is what drives the media to report on the deaths.  We HAVE TO keep it in perspective.
  • The vaccine scare–The H1N1 vaccine was created in the SAME process that the regular seasonal flu vaccine is (they would have mixed the seasonal flu vaccine and the H1N1 vaccine in the SAME shot if they had had the time).  The vaccine is safe (as safe as the regular seasonal flu vaccine.
  • tamiflu–NOT recommended unless person with the flu is immunocompromised otherwise tamiflu is NOT recommended (and it is NOT without it’s own side effects)
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Wear a HELMET!

My ENTIRE family wears helmets when they ride bikes, skateboard, razor, etc.  I started wearing a helmet after I saw an 11 year old girl die before my eyes when I was in training.  She was roller blading on her street and a car at low speed hit her.  She tore one of the main arteries in her brain, and you could see the blood gushing out of her nose–it was very graphic and memorable.  Wear a HELMET!

I am always amazed at how few kids wear helmets in my neighborhood even when driving around in the motorized scooters.  Wear a HELMET!

I just received an email about a kid who was not wearing a helmet and fell off his skateboard and had multiple skull fractures and a severe concussion.  This is what his mom said in her email:  “If there is a lesson as a parent that Mark and I have taken, it is to hug your child every day and look at them for the perfect creatures that they are, and as a true gift from God.  Don’t sweat the small stuff, because life can change in an instant!  And, . . . to make them WEAR A HELMET, even if they think they are too cool.  That includes us as parents, as I will be purchasing myself one before our next bike ride.  So to my friend Patricia, who I always see riding with her helmet on and giggle, I will soon be in your club!”

Wear a HELMET!

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Francis Collins, Part 1 & ‘finding waldo’

Have you ever played the book game ‘finding waldo’? I thought I would share this brief article and see if anyone wants to post a comment sharing with us what they find ironic/problematic with this article that was the lead article in medicine’s premier journal-The New England Journal of Medicine. I will share what I found in a follow up post.

Opportunities and Challenges for the NIH — An Interview with Francis Collins
Robert Steinbrook, M.D.
Francis Collins, the physician and geneticist who was sworn in as the 16th director of the National Institutes of Health (NIH) in August 2009, anticipates scientific opportunities and budgetary challenges. Although the NIH received $10.4 billion in new funding under the American Recovery and ReinvestmentAct, the money must be spent by September 2010 and the institutes’budget has otherwise been relatively flat since 2003 (see graph).1 Fiscal year 2011 begins on October 1, 2010, and prospects are uncertain.

Collins, 59, has led the Human Genome Project and directed the National Human Genome Research Institute at NIH; his laboratory has identified many important genes. He also established the BioLogos Foundation, which addresses the interface between science and faith, and wrote a best-selling 2006 book, The Language of God: A Scientist Presents Evidence for Belief. Some observers expressed concern that his personal religious beliefs would affect his judgments as NIH director.2 When he became director, Collins resigned from the foundation, ended his involvement in public discussions about science and faith, and provided reassurances that his agenda for the institutes is scientific, not religious.
(vol 361:1321-1323 October 1, 2009)

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Healthcare Reform: Finally a concise & accurate article

I have been reading all the articles about the healthcare issue in the New England Journal of Medicine–medicines premier journal.

I have been disappointed by the wordiness, political biases, and inaccuracies of the articles in the NEJM.  I have finally come across a concise & accurate article:

Health Care Reform and Clinical Culture

It is a tired and cynical cadre of physicians who will implement health care reforms. Yet few published perspectives include the view from the factory floor. The usual platitudes about changing financial incentives, increasing efficiency, and delivering high-quality care sound naïve to clinicians who deal with the imperfections of human nature and the messy effects of illness on patients. Doctors are already, by training, sophisticateddecision-making machines, capable of achieving extreme efficiency through the use of heuristics and experience.The main problems that clinicians face in achieving efficiency and reducing costs are, first, a perceived need for certainty in diagnosis and treatment — a need driven by secular expectations and malpractice concerns; second, gross inefficiency created by obligatory documentation to satisfy billing requirements that have little value for clinical care; and third, restrictions on the use of clinical judgment that could avoid excessive testing. None of these problems, whose solutions would save money and time, have been incorporated into the national discussion about reform.

One change that would augment the role of clinical judgment would be for the health care system to resist the temptation to require adoption of often-elusive “best practices.” Therehas been an assumption by analysts that published clinical trials provide a sound guide for therapy, but all reputable studies report odds, hazard ratios, and effect sizes, almost all ofwhich are small or modest. Absolutes are discordant with the realities of sickness and health. There may be guidelines and measurable outcomes for mundane problems, but for the vast majority of daily doctor’s visits and hospital decisions, incremental or recursive approaches to diagnosis and treatment are more effective and efficient.

A second reform should be to limit malpractice awards so as to reduce physicians’ fear of lawsuits. Regardless of the arguments of defenders of open-ended malpractice payments, this insidious concern is a major driver of overtesting and overconsulting.

A third key reform would be to eliminate the time sink of the comprehensive exam and its lengthy documentation required by Medicare — a requirement that is likely to be adopted or exaggerated in any new codified system. Immaterial information is already cluttering the electronic medical record. My survey of neurology notes, which I presume would be among the most thoughtful in medicine, shows that less than one fifth of the average note is taken up with analysis and discussion of the patient’s problem; the remainder is part of the “waste” in modern medical care.

Fourth, payment codes should be reduced to “simple” and “complex” — or at least the numerous billing levels and codes should be conflated, and payment should be based on diagnosis and time expended. Physicians should also be paid for their expertise.

Health care reform can redress slowly accrued and detrimental cultural changes, particularly the loss of reliance on clinical judgment. It would be a missed opportunity if practicing physicians (as contrasted to their representative bodies and societies) were excluded from the center of the conversation. The efficient use of the professional workforce will be more powerful than rules.
Allan H. Ropper, M.D.
Brigham and Women’s Hospital
Boston, MA

This article (10.1056/NEJMopv0907607) was published on August 26, 2009, at NEJM.org.

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Medical Myth #6 (example #4): Placebo’s don’t work

The power of the placebo is so incredible and interesting that I have shared many examples from this thought provoking book (Enjoy example #4):
Hippocrates’ Shadow: Secrets from the House of Medicine (David Newman)

“Moerman describes a study in which placebo injections for pain are given to two sets of patients under nearly identical circumstances. In the first, the physician is told that theres no chance that a real narcotic medication will be given. In the second, the physician is told that theres a chance that the patient will receive a narcotic. In both cases the patient receives a placebo, but the placebo is far more effective in relieving pain in the second case, when the physician believes that a narcotic may be in the injection. While the impact is very different in these cases, the only difference is in the physicians beliefs.”

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Medical Myth #6 (Example #5): Placebo’s don’t work

This is the 5th and final example of the placebo effect from Hippocrates’ Shadow: Secrets from the House of Medicine (David Newman):

“In 1961 Henry Beecher, a distinguished Harvard professor and researcher of the placebo effect, published a paper comparing sham heart surgeries in two groups of patients from two different studies (the paper discussed only those who had received shams, not the real surgeries).* Using observations of interactions between the physicians and patients Beecher described the surgeons as enthusiasts or skeptics based on their attitude toward the procedure and toward the patients having the procedure. Patients of the enthusiast surgeons achieved nearly four times more complete relief of their chest pain and heart problems than patients of the skeptics….

…The healing is in the psychosocial and biologic contextthe contact, the ceremony, the bond between doctor and patient. The healing is not in the pill or the scalpel any more than the strength to run faster was in the sneaker, or the taste was in the color of the can….

…Medical education, taught primarily by physicians, is a reflection of medical culture. Currently, we dont routinely teach the meaning response. In heart disease and major depression, to name only two, estimations of the effect of placebo pills have shown that theyre proportionally more effective than most real medications.”

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Medical Myth #6 (example #3): Placebo’s don’t work

Here is yet another example of the power of the placebo from Hippocrates’ Shadow: Secrets from the House of Medicine (David Newman)

“…Just five months after Dr. Freeds group published their work, a group in Vancouver, Canada, published a study…using a brain imaging technique called positron emission tomography scans, or PET scans, the researchers recorded the production of dopamine from the diseased areas of the brains of Parkinsons patients. While this had been done before, the researchers performed the images on an unusual group: patients from the active treatment and placebo groups of a trial being done to test a new drug for Parkinsons at their medical center. The PET scans showed that patients receiving placebos had visibly and measurably increased dopamine output from the diseased cells. The PET scans had allowed researchers for the first time to see the placebo effect….

Skeptics have argued that these studies dont provide evidence of a true physiologic placebo effect because pain, or even nausea, can be a subjective measurement. But dopamine output in the brain, and endorphins, are not subjective. Physical healing is also not subjective. Just as more pain reduction is seen with two placebo pills than with one, ulcers seen by endoscopy in the lining of the stomach or intestine heal more quickly when a patient is given two placebo pills rather than one. Real medicine reduces high blood pressure, but an inert pill does so as well, albeit somewhat less effectively. Real medications for asthma dilate the lung passages, making it easier to breathe; but if you tell an asthma patient that hes going to receive a medication that will dilate his lung passages, and then give him an inhaled placebo, his lung passages dilate. The patterns of placebo response are virtually identical to the patterns seen when using an effective pill.”

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Healthcare Debate: Malpractice Reform

3rd and final article from Emergency Physicians Monthly…saved the best for last.  This is the single most important issue in all of the physicians minds that I have spoken with, but of course, no one in politics has addressed it. I wonder why? Hmmm…

Just A Spoonful of Reform Print E-mail
by Greg Henry, MD

These are clearly the times that try men’s souls, or at least their patience. As health care reform is being contemplated throughout the country, there are more and more chances that we’ll get it wrong as opposed to getting it right. However, disagreements aside, emergency physicians need to come together and decide what goals we will put forward. We need to stop wasting time asking whose name is on the bill and start asking if the policies will meet the long-term goals of our specialty. There are many policy areas where emergency physicians need to get involved, from services rendered to workforce issue, but let’s begin with the medical-legal structure since we are most likely to get some unanimity in this area. I’ll give some ideas that I think are straightforward and could be a win-win situation for the government.

Ever since the passage of EMTALA, emergency physicians have been de facto employees of the federal government. We don’t get to decide whom we see. We have no way of deciding who walks in the door or whether we’re ever going to see a dime for the services rendered. We also have no way of knowing if those patients, who may not even pay the bill, are going to sue us. I think that there are multiple things that can be done right now with the Obama administration to address this issue.

The first thing is to agree that rendering care to those in need is not the problem. One of my greatest badges of honor is the ability to say that I have never denied anyone health care based on their ability to pay. We are the physicians who carry the staff of Asclepius the highest. We are the ones who, any moment of the day and night, see anyone and give out health care. This is part of who we are and should not change. But give me a break! This ought to be recognized and rewarded in at least two ways. First, emergency physicians should be able to calculate the value of the free care they were mandated to give out in a given year and then deduct some portion of that amount from their income taxes. If, in a year, I give out $160,000 of free care – which I’m perfectly happy to do – the government ought to be perfectly happy to let me at least write the loss off on my taxes. What’s wrong with this idea? I understand that this would reduce the income coming to the government, but if they actually had to pay for that same care, it would cost even more.  The federal government needs to recognize that emergency physicians are acting as conscripted government workers and should receive some sort of compensation.  Don’t give me 100%. No insurance company gives me 100% (and ever since California cancelled balanced billing none of us will ever again expect to see 100% of charges) but don’t let me drown in red ink! The logic is straightforward. As tax-paying citizens, we do not expect Boeing to make planes for the U.S. government and not get paid for it. Why would we expect physicians to give out health care and not get paid?

Second, there is no reason for EPs to bear the liability of every patient who walks into the emergency department. We need to have some reasonable liability relief. I believe that since we have essentially been named the de facto employees of the federal government, we should be covered by the federal government like any other federal employee. If the mailman runs over your mailbox, the government handles that liability. The concept is called “respondeat superior,” or “let the master answer.” Well since our master, the federal government, has decided what we will do and what we will get, let him also be involved in the malpractice issue. For physicians of any specialty who are mandated by law to see ED patients, liability should be handled through a no-fault system paid for by the federal government. In some states, this might mean as much as $40,000 savings in insurance costs. Having a federal system that would, without fear or favor, use a no-fault system to evaluate harm and properly compensate patients who are truly damaged, would work out for the benefit of physicians and patients alike.

And finally, it has been estimated that less than 15% of the funds that go into malpractice insurance policies actually wind up in the pockets of patients. Most reasonable physicians could look at a situation and decide whether a patient was truly harmed by the actions of other physicians. So be it. But do not let 40% of the money go directly into the pockets of attorneys. Both plaintiff and defense attorneys strip us down for money. Do not let people who are on the fringes of health care continuously drain the pockets of emergency physicians. It just doesn’t make sense. A simple act of assuming liability and creating boards which look at the extent of injuries would go a long way towards lowering health care costs, making physicians more comfortable with their clinical decision-making and stopping the mindless ordering of tests which are part of the “cover-your-ass” medicine which supposedly protects us from lawsuits. These few simple actions could be just the teaspoon of sugar needed to help the bitter pill of health care reform go down smoothly.

Greg Henry, MD, is the founder and CEO of Medical Practice Risk Assessment, Inc. Dr. Henry is a past president of ACEP and directed an ED for 21 years.
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Healthcare Debate: The Kennedy/Dodd Bill

This is the 2nd article of 3 from Emergency Physicians Monthly on healthcare reform issue.

Please also see the GREAT comments to this important article.

The Kennedy/Dodd Bill: A Physician’s Analysis
The Senate Health, Education, Labor, and Pensions Committee, chaired by Sen. Chris Dodd (D-Conn), passed a health bill on July 15th that finally laid out the specifics of the biggest overhaul of health care in history. You can read a staff draft of the bill HERE (text file). Here are the highlights.
by Mark Plaster, MD
Executive Editor
First, everybody has to be in a “qualified plan” as defined by the Secretary of Health and Human Services. If you can’t prove that you have been insured for every month of the last year, you’ll be assessed a surtax to cover the government covering you. Of course, if you don’t pay taxes, as an increasing number of people don’t, it won’t effect you. If you are an employer, you have to pay a minimum percent or dollar amount of the premium for the plan, but only if you don’t already offer insurance to your employees. If you do, and the plan is ‘qualified’, then you don’t pay the surtax. And how much is the tax? Whatever the Sec of HHS deems is necessary to get everyone to participate.

But what defines a “qualified plan”? The Kennedy bill mandates guaranteed issue and renewal. Everybody can get insurance and nobody can be canceled, regardless of your past health or your lifestyle choices. The plans could not charge more for people who engage in increased risk lifestyles or habits, such as alcoholism, drug addiction, obesity, etc. Each qualified plan must have a modified community rating to pay more to areas of the country where medicine costs more. There can be no caps on annual or lifetime benefits. And family policies must cover ‘children’ up to age 26. Qualified plans must have at least three levels of cost sharing, cover a list of preventive services approved by the government and cover “essential health benefits,” as defined by the new Medical Advisory Council (MAC), who would be appointed by the Secretary of Health and Human Services. The MAC would have control over such services as out patient care, emergency services, all hospitalization, maternity care, mental health, pharmaceuticals, rehab, and any other services that it deemed essential to health. The MAC would also define what was “affordable and available coverage” for different income levels.

The Kennedy bill would expand Medicaid to cover everyone up to 150% of the poverty level, with the federal government paying for all the increased costs to the states. People making between 150% and 500% of the poverty level would be subsidized by the government on a sliding scale. To put that in perspective, a family of four making $110,000 would still get a small subsidy. People living in big cities would get larger subsidies. Of course, this Committee has no ability to write actual tax law to fund this legislation. That’s up to the finance committee.
The largest of all the hurdles in the bill is the “public plan option,” in which the government will offer to include people in Medicare. To sweeten the offer, the legislation calls for physicians to be paid at Medicare rates plus 10%. The legislation makes no mention of the future payments. Nor does it acknowledge that the Sustainable Growth Rate calculations for physician reimbursement from Medicare are currently calling for a 21% cut in compensation. Group health plans with 250 or fewer members would be prohibited from self-insuring, leaving ERISA to big businesses.
The legislation calls for health insurance to be sold through “gateways” set up by state governments that market only “qualified plans.” These “gateways” would have “navigators”, also paid by the state, the enroll people. The organizations receiving these funds could be community organizer groups or unions.
As previously stated, an interesting loophole exists in this bill that would exempt health insurance plans that met the standards of a “qualified plan” that were in existence before the legislation. The effect of this could make it very difficult to change jobs, if the new job was paying the higher cost of mandated insurance.
Another huge hurdle is the definition of who must get insurance. The bill defines an “eligible individual” as “a citizen or national of the United States or an alien lawfully admitted to the United States for permanent residence or an alien lawfully present in the United States.” This appears to open the door to medical coverage to every illegal alien who is granted some type of amnesty.
The only hope for controlling costs in this bill is the re-introduction of the gatekeeper concept that was tried 20+ years ago. Under this scheme, the gatekeeper, called a “medical home”, is a patient’s private practitioner would have the control of whether a specialty referral was made, tests were ordered, or hospitalization occurred. He would have 10% of his compensation held back each year until it was known whether he met the limits on spending on each patient. If he failed to meet the spending goals for each patient, he would have to pay for the care from his own pocket.
What are the potential effects of the Kennedy-Dodd bill, should it pass? First is the price tag. Those who pay most of the tax revenues of the country would see their taxes rise significantly. Businesses will have to incorporate these increased costs by lowering wages, hiring fewer people, or moving to other areas of the globe. Small business could be hardest hit, though there is talk of a small business exemption. But it is unlikely that tax increases on the upper income taxpayers would be enough. President Obama has already started to reverse his campaign pledge that those making less that $250,000 “would not see [your] income tax rise one penny.” He is now admitting that medical benefits would need to be taxed. So if someone making $80,000 per year was receiving a $10,000 per health plan, he would be taxed on $90,000, thereby increasing his taxes up to $2,000 without any increase in salary.
The biggest effect would be 50 million new patients. With the current saturation of many private physician practices, many of those patients would come to the ED.  Convincing gatekeepers to refer and specialists to accept these patients could get significantly more difficult, exacerbating wait times and holds.
Another huge effect would be the power of the Medical Advisory Committee. Unelected, virtually unsupervised individuals would control what health care looked like in this country, who was covered, who paid, and what services were covered at what compensation.
Cost shifting from the healthy to the unhealthy and those who engage in risky lifestyles would increase dramatically. The only control of this would be through lobbying the members of the MAC.
And finally, this bill would not effect members of Congress despite Mr. Obama’s campaign promise to offer Americans “the same kind of coverage that members of Congress give themselves.”
Mark Plaster, MD, is the Executive Editor of Emergency Physicians Monthly
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Healthcare Debate: The Wrong Questions

This the 1st of 3 brief articles written by physicians regarding their concerns with healthcare reform:

“The Wrong Question” Print
by Mark Plaster, MD

I sat transfixed reading the email from a friend. I couldn’t believe what I was reading. Finally my wife broke into my thoughts. “What are you doing? I’ve been calling you for ten minutes. And when I find you, you’re staring at the computer, shaking your head and mumbling.”

“I can’t believe what I’m reading,” I mumbled. “This health care debate has turned everything on its head.”

“What ARE you talking about?”

“You know that story I used to tell about calling that lazy urologist up late one night? I asked for his help to cath a patient with a stricture and he says, ‘How old’s the patient?’. When I tell him the patient’s 81, he just growls “He’s peed enough,” and slams down the phone. Do you remember that story?”

“Yes,” she said with a scowl. “I hate that story.”

“Well, that seems to be the new strategy for reducing the cost of health care while extending it to the uninsured. This article that David sent me is about a guy who feels guilty for getting treated for his prostate cancer.”

“I don’t get it.”

“Yeah, he says maybe he should’ve just died and saved the money for the system.”

“That’s kind of twisted,” she said with a shrug. “I can maybe see someone deciding to forgo treatment if there isn’t any hope of recovery.”

“That’s OK if you are deciding for yourself. But this guy got his treatment. He has a good chance of full recovery. And now he’s trying to guilt other people into forgoing treatment in the interest of saving money.”

“Just for the sake of argument . . . ” she started.

“I can always depend on you to be the devils advocate. I can see you starting to sprout horns already.”

“No, seriously,” she said, “haven’t you always said that people spend more in the last year of life than in all the other years combined? Couldn’t the system save a lot by foregoing a lot of needless treatment?”

“Who says it’s needless? You never really know if a treatment is going to work. What doesn’t work for one person might work just fine for you. I don’t want anybody making that decision for my life, but me.”

“But what if you are too senile to make that decision,” she said, starting to warm to the debate. “You wouldn’t want us to spend everything we had on every unproven treatment, would you?”

“I will concede that we shouldn’t be using insurance money to pay for treatments that have not been shown to work. But if I’ve been paying into the system all my life, shouldn’t I get a chance to try some experimental treatments?”

“Well . . . ”

“And I hate it when you throw the ‘senile’ thing at me.” I furrowed my brow and gave her a suspicious pout. “There’s nothing wrong with a little senility.”

“Oh, come on. You don’t want to just sit around in a nursing home and drool like that lady you used to tell me about, the one you had to change a diaper for all the time.”

“The lady you’re talking about was named Gladys and she seemed perfectly content to smile, drool, and poop in her diaper. Like I said, there’s nothing wrong with a little senility. The fact is that I’m sort of looking forward to a little dementia. I want to live with one of our kids when I get senile. It will pay them back for all the years that I changed their diapers.”

“When did you ever change a diaper?” she snapped back.

“Do you remember that time that we were…you know…having a little roll in the sack and one the babies started crying. And you ran in and brought him to our bed and he threw up on me. Do you remember that? Talk about ruining the moment.”

“Talk about holding a grudge,” she said shaking her head.

“I can still feel the sensation of baby vomit running down my bare legs. I spent the rest of the night picking chunks of beets out of my chest hair.”

“That made quite and impression, didn’t it?”

“It’s a nightmare I’ll never forget,” I said, mocking her mocking me. “I’m just saying that we took care of the kids when they were babies. Why shouldn’t they take care of us when we are old.”

“OK,” she replied slowly. “But you lost me on how this relates to the health care reform debate.”

“Don’t you see? The whole debate is turning things upside down. People who haven’t paid anything into the system are claiming that they have a right to healthcare. And people who have been paying into the system for years are being guilted into refusing to take what is rightfully owed to them. The throw-up story was just a colorful aside.”

“But you’re not denying that we spend a disproportionate amount of the total health care expenditure of the country on the elderly?” she said trying to score a minor victory.

“OK, maybe we do a little. But all kidding aside. Every day of every life is valuable. And we shouldn’t be pitting one group against another in an effort to balance the health care budget. It’s not a zero sum game.”

“Well, one thing’s for sure. The country can’t continue to spend more and more on health care.”

“Do you hear what you’re saying? You’re beginning to sound just like all those bureaucrats in Washington. People should be able to spend their money on whatever is important to them. It’s pooled insurance money, or worse, government insurance money, that has people thinking that how they spend their health care dollar is the business of other people.”

“So you would like to see us go back to a purely free enterprise medical system? First, that’s not going to happen. This isn’t the 50’s. And second, what would happen to the people who don’t have enough to pay for expensive medical care. I know that you can be a cold, heartless, S.O…”

“Hey, don’t start talking about lawyers again.”

“… but I don’t think you are advocating cutting people out of the system.”

“Of course not,” I said, becoming serious again. “There’s more than enough excess in the system to pay for truly needed medical care for everyone. And if you want something that has marginal value, you should be able to get it. But you should have to pay for it. If you can’t afford something that has marginal value, then you shouldn’t get it. It’s that simple.”

“It’s that simple, huh? You seem to have it all figured out. So why is Congress having such a tough time with this?”

“They’re asking the wrong questions. And they are pitting one group against another, like they always do.”

“There’s just one question remaining, smarty pants. Who is going to decide what is ‘truly needed medical care’?”

“We are,” I said confidently. “Physicians are the only ones who can make that decision. All we need are education and ethics. The basics. And we need protection from the lawyers when we have to make a close call or when a bad outcome occurs.”

“Now you’re the one talking about lawyers.”
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Promising the Impossible

The OC Register had a concise and important editorial in today’s newspaper regarding the healthcare issues.  As always please share your thoughts with us.

Promising the impossible

Reformers’ health care promises not worth a wooden nickel.

John Stossel

John Stossel
Syndicated columnist,
Co-anchor of ABC News’ “20/20”

I keep reading about health-care “reform,” but I have yet to see anyone explain how the government can make it easier for more people to obtain medical services, control the already exploding cost of those services and not interfere with people’s most intimate decisions.

You don’t need to be a Ph.D. in economics to understand that government cannot do all three things. (Judging by what Paul Krugman writes (http://tinyurl.com/lgpr4o), a Ph.D. may be an obstacle.)

The New York Times describes a key part of the House bill: “Lawmakers of both parties agree on the need to rein in private insurance companies by banning underwriting practices that have prevented millions of Americans from obtaining affordable insurance. Insurers would, for example, have to accept all applicants and could not charge higher premiums because of a person’s medical history or current illness” (http://tinyurl.com/knzczq).

No more evil “cherry-picking.” No more “discrimination against the sick. But that’s not insurance. Insurance is the pooling of resources to cover the cost of a possible but by no means certain misfortune befalling a given individual. Government-subsidized coverage for people already sick is welfare. We can debate whether this is good, but let’s discuss it honestly. Calling welfare “insurance” muddies thinking.

Such “reform” must increase the demand for medical services. That will lead to higher prices. Obama tells us that reform will lower costs. But how do you control costs while boosting demand?

The reformers make vague promises about covering the increased demand by cutting other costs. We should know by now that such promises aren’t worth a wooden nickel. The savings never materialize.

Some of the savings are supposed to come from Medicare. The Times reports “Lawmakers also agree on proposals to squeeze hundreds of billions of dollars out of Medicare by reducing the growth of payments to hospitals and many other health care providers.”

With the collapse of the socialist countries, we ought to understand that bureaucrats cannot competently set prices. When they pay too little, costs are covertly shifted to others, or services dry up. When they pay too much, scarce resources are diverted from other important uses and people must go without needed goods. Only markets can assure that people have reasonable access to resources according to each individual’s priorities.

Assume Medicare reimbursements are cut. When retirees begin to feel the effects, AARP will scream bloody murder. The elderly vote in large numbers, and their powerful lobbyists will be listened to.

The government will then give up that strategy and turn to what the Reagan administration called “revenue enhancement”: higher taxes on the “rich.” When that fails, because there aren’t enough rich to soak, the politicians will soak the middle class. When that fails, they will turn to more borrowing. The Fed will print more money, and we’ll have more inflation. Everyone will be poorer.

The Times story adds: “They are committed to rewarding high-quality care, by paying for the value, rather than the volume, of [Medicare]services.”

Value to whom? When someone buys a service in the market, that indicates he values it more than what he gives up for it. But when the taxpayers subsidize the buyer, the link between benefit and cost is broken. Market discipline disappears.

Listening to the health-care debate, I hear Republicans and Democrats saying it’s wrong to deny anyone anything. That head-in-the-sand attitude is why Medicare has a $36-trillion unfunded liability (http://tinyurl.com/72bm5h). It’s not sustainable – and they know it.

They’ve given us a system that now can be saved only if bureaucrats limit coverage by second-guessing retirees’ decisions. Government will decide which Medicare services have value and which do not. Retirees may have a different opinion.

One may be willing to give up the last year of life if he’s in pain and has little hope for recovery. Another may want to fight to the end. But when taxpayers pay, the state will make one choice for all retirees.

Now, to reduce the financial burden of the medical system, Obama proposes a plan that inevitably will extend the second-guessing to the rest of us. So much for his promise not to interfere with our medical decisions.

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Obama’s Outlandish Statements Against Physicians

Obama has accused doctors of doing tonsillectomies to make money, and he has falsely implied that surgeons cut off legs for a profit. The actual reimbursement for an amputation is approx 800$ NOT 40,000$. This kind of rhetoric is alarming and disturbing. Please spread the news that this must stop.

Please contact our state senators and voice your concerns regarding the healthcare reform proposals: Barbara Boxers number is 213-894-5000 and Diane Feinstein’s number is 619-231-9712.

CMA Objects to Obama’s Misleading Statements about Physicians

President Obama has recently made his case for health reform by using some misleading and inflammatory rhetoric. While discussing the importance of prevention, he has implied that physicians’ treatment decisions are financially motivated and incorrectly stated that surgeons are paid $30,000 to $50,000 to amputate a foot. CMA wholeheartedly agrees with the President on the importance of prevention, but the examples he used were inaccurate and offensive and could undermine the trust central to the physician-patient relationship.

At a town hall meeting in New Hampshire on August 11, President Obama said, “All I’m saying is let’s take the example of something like diabetes, one of — a disease that’s skyrocketing, partly because of obesity, partly because it’s not treated as effectively as it could be. Right now if we paid a family — if a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they’re taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that’s $30,000, $40,000, $50,000 — immediately the surgeon is reimbursed. Well, why not make sure that we’re also reimbursing the care that prevents the amputation, right? That will save us money. (Watch the video here.)

At a press briefing on July 22, President Obama said, “Part of what we want to do is to make sure that those decisions are being made by doctors and medical experts based on evidence, based on what works…. Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that’s out there. … the doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out … I’d rather have that doctor making those decisions based on whether you really need your kid’s tonsils out, or whether … something else would make a difference…. So part of what we want to do is to free doctors, patients, hospitals to make decisions based on what’s best for patient care.” (Watch the video here.)

CMA released the following statement to the media regarding the President’s statements.

August 13, 2009

Sacramento – The California Medical Association issued the following statement today, attributable to CMA President Dev GnanaDev:

“CMA is deeply concerned about two examples of medical treatment recently used by President Obama to make his case for health reform.
“In the first example, he stated that surgeons make $30,000 to $50,000 to amputate a foot of a diabetic. This assertion is false. Medicare pays surgeons $589 to $767 for a foot amputation. Medi-Cal pays $420 for the same. Hospital and other associated costs may add up to the greater amount, but it is incorrect and misleading to suggest the surgeon’s costs are responsible for that figure.

“We share the President’s belief that we need to put greater resources towards primary and preventive care in order to keep people healthier and help address the nation’s rising health care costs. However, preventive care will never obviate the need for qualified physicians and surgeons to take corrective action to improve or save people’s lives.

“In the second example, the President suggested that physicians take out children’s tonsils to make more money. This implication is inaccurate and offensive.

“Doctors treat patients based on the health needs of the patient, not the financial incentives. When science suggests overutilization may be occurring, the medical profession has responded with improved guidelines to more fully inform physicians of the risks and benefits of any treatment or procedure.

“The California Medical Association is committed to reforming our health system to increase access to quality care and reduce rising health care costs. To achieve health reform, the American people must be able to trust our elected officials and the statements they make regarding health care.

“Patients trust their doctors. That trust is critical to an effective and successful doctor-patient relationship. We urge the President to stick to the facts and avoid the kind of misleading and inflammatory rhetoric that would erode that trust and derail our efforts to increase access to quality care and control rising health care costs.”

Dr. GnanaDev is a trauma surgeon and chief of the medical staff at Arrowhead Regional Medical Center, San Bernardino County’s public hospital.

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Healthcare Reform: Better off being a dog

Here is a very sobering, humorous, and truthful article about what is at stake in the healthcare reform debate from the WSJ:

In the last few years, I have had the opportunity to compare the human and veterinary health services of Great Britain, and on the whole it is better to be a dog.

As a British dog, you get to choose (through an intermediary, I admit) your veterinarian. If you don’t like him, you can pick up your leash and go elsewhere, that very day if necessary. Any vet will see you straight away, there is no delay in such investigations as you may need, and treatment is immediate. There are no waiting lists for dogs, no operations postponed because something more important has come up, no appalling stories of dogs being made to wait for years because other dogs or hamsters come first.

The conditions in which you receive your treatment are much more pleasant than British humans have to endure. For one thing, there is no bureaucracy to be negotiated with the skill of a white-water canoeist; above all, the atmosphere is different. There is no tension, no feeling that one more patient will bring the whole system to the point of collapse, and all the staff go off with nervous breakdowns. In the waiting rooms, a perfect calm reigns; the patients’

relatives are not on the verge of hysteria, and do not suspect that the system is cheating their loved one, for economic reasons, of the treatment which he needs. The relatives are united by their concern for the welfare of each other’s loved one. They are not terrified that someone is getting more out of the system than they.

The latter is the fear that also haunts Americans, at least those Americans who think of justice as equality in actual, tangible benefits. That is the ideological driving force of health-care reform in America. Without manifest and undeniable inequalities, the whole question would generate no passion, only dull technical proposals and counterproposals, reported sporadically on the inside pages of newspapers. I have never seen an article on the way veterinary services are arranged in Britain: it is simply not a question.

Nevertheless, there is one drawback to the superior care British dogs receive by comparison with that of British humans: they have to pay for it, there and then. By contrast, British humans receive health care that is free at the point of delivery. Of course, some dogs have had the foresight to take out insurance, but others have to pay out of their savings. Nevertheless, the iron principle holds: cash on delivery.

But what, I hear social philosophers and the shade of the late John Rawls cry, of British dogs that have no savings and cannot afford insurance? What happens to them? Are not British streets littered with canines expiring from preventable and treatable diseases, as American streets are said by Europeans to be littered with the corpses of the uninsured? Strangely, no. This is not because there are no poor dogs; there are many. The fact is, however, that there is a charitable system of veterinary services, free at the point of delivery, for poor dogs, run by the People’s Dispensary for Sick Animals, the PDSA. This is the dog’s safety net.

Honesty compels me to admit that the atmosphere in the PDSA rather resembles that in the National Health Service for British humans, and no dog would go there if he had the choice to go elsewhere. He has to wait and accept what he’s given; the attendants may be nice, or they may also be nasty, he has to take pot luck; and the other dogs who go there tend to be of a different type or breed, often of the fighting variety whose jaws once closed on, say, a human calf cannot be prised open except by decapitation.

There is no denying that the PDSA is not as pleasant as private veterinary services; but even the most ferocious opponents of the National Health Service have not alleged that it fails to be better than nothing.

What is the solution to the problem of some dogs receiving so much better, or at least more pleasant, care than others? Is it not a great injustice that, through no fault of their own, some dogs are treated in Spartan conditions while others, no better or more talented than they, are pampered with all the comforts that commerce can afford?

One solution to the problem of the injustice in the treatment of dogs would be for the government to set up an equalizing fund from which money would be dispensed, when necessary, to sick dogs, purely on the basis of need rather than by their ability to pay, though contributions to the fund would be assessed strictly on ability to pay.

Of course, from the point of view of social justice as equality, it wouldn’t really matter whether the treatment meted out to dogs was good or bad, so long as it was equal. And, oddly enough, one of the things about the British National Health Service for human beings that has persuaded the British over its 60 years of existence that it is socially just is the difficulty and unpleasantness it throws in the way of patients, rich and poor alike: for equality has the connotation not only of justice, but of hardship and suffering. And, as everyone knows, it is easier to spread hardship equally than to disseminate blessings equally.

I hope I shall not be accused of undue asperity towards human nature when I suggest that the comparative efficiency and pleasantness of services for dogs by comparison with those for humans has something, indeed a great deal, to do with the exchange of money. This is not to say that it is only the commercial aspect of veterinary practice that makes it satisfactory: most vets genuinely like dogs at least as much as most doctors like people, and moreover they have a pride in professional standards that is independent of any monetary gain they might secure by maintaining them. But the fact that the money they receive might go elsewhere if they fail to satisfy surely gives a fillip to their resolve to satisfy.

And I mean no disrespect to the proper function of government when I say that government control, especially when highly centralized, can sap the will even of highly motivated people to do their best. No one, therefore, would seriously expect the condition of dogs in Britain to improve if the government took over veterinary care, and laid down what treatment dogs could and could not receive.

It might be objected, however, that Man, pace Professor Singer, is not a dog, and that therefore the veterinary analogy is not strictly a correct or relevant one. Health economics, after all, is an important and very complex science, if a somewhat dull one, indeed the most dismal branch of the dismal science. Who opens the pages of the New England Journal of Medicine to read, with a song in his heart, papers with titles such as ‘Collective Accountability for Medical Care Toward Bundled Medicare Payments,’or ‘Universal Coverage One Head at a Time – the Risks and Benefits of Individual Insurance Mandates’? On the whole, I’d as soon settle down to read the 110,000 pages of Medicare rules.

A few simple facts seem established, however, even in this contentious field. The United States spends a greater proportion of its gross domestic product on health care than any other advanced nation, yet the results, as measured by the health of the population overall, are mediocre. Even within the United States, there is no correlation between the amount spent on health care per capita and the actual health of the population upon which it is spent.

The explanation usually given for this is that physicians have perverse incentives: they are paid by service or procedure rather than by results. As Bernard Shaw said, if you pay a man to cut off your leg, he will.

But the same is true in France, which not only spends a lesser proportion of its GDP on health care than the U.S. but has better results, as measured by life expectancy, and is in the unusual situation of allaying most of its citizens’ anxieties about health care. However, the French government is not so happy:

chronically in deficit, the health-care system can be sustained only by continued government borrowing, which is already at a dangerously high level. The French government is in the situation, uncomfortable for that of any democracy, of having to reform, and even destroy, a system that everyone likes.

Across the Channel, there is very little that can be said in favor of a health system which is the most ideologically egalitarian in the western world. It supposedly allots health care independently of the ability to pay, and solely on the basis of clinical need; but not only are differences in the health of the rich and poor in Britain among the greatest in the western world, they are as great as they were in 1948, when health care was de facto nationalized precisely to bring about equalization. There are parts of Glasgow that have almost Russian levels of premature male death. Britain’s hospitals have vastly higher rates of methicillin-resistant Staphylococcus aureus (a measurement of the cleanliness of hospitals) than those of any other European country; and survival rates from cancer and cardiovascular disease are the lowest in the western world, and lower even than among the worst-off Americans.

Even here, though, there is a slight paradox. About three quarters of people die of cardiovascular diseases and cancer, and therefore seriously inferior rates of survival ought to affect life expectancy overall. And yet Britons do not have a lower life expectancy than all other Europeans; their life expectancy is very slightly higher than that of Americans, and higher than that of Danes, for example, who might be expected to have a very superior health-care system. Certainly, I would much rather be ill in Denmark than in Britain, whatever the life expectancy statistics.

Perhaps this suggests that there is less at stake in the way health-care systems are organized and funded, at least as far as life expectancy is concerned (not an unimportant measure, after all), than is sometimes supposed. Or perhaps it suggests that the relationship of the health-care system to the actual health of people in societies numbering many millions is so complex that it is difficult to identify factors with any degree of certainty.

In the New England Journal of Medicine for July 3, 2008, we read the bald statement that ‘Medicare’s projected spending growth is unsustainable.’ But in the same journal on Jan. 24, 2008, under the title ‘The Amazing

Non-collapsing U.S. Health Care System’ we had read that ‘For roughly 40 years, health care professionals, policy-makers, politicians, and the public have concurred that the system is careening towards collapse because it is indefensible and unsustainable, a study in crisis and chaos. This forecast appeared soon after Medicare and Medicaid were enacted and have never retreated. Such disquieting continuity amid changes raises an intriguing question: If the consensus was so incontestable, why has the system not already collapsed?’

The fact that collapse has not occurred in 40 years does not, of course, mean that it will not collapse tomorrow. The fact that a projection is not a prediction works in all directions: prolonged survival does not mean eternal survival, any more than a growth in the proportion of GDP devoted to health care means that, eventually, the entire GDP must be spent on health care.

Therefore I, who have no solution to my own health-care problems, let alone those of the United States, say only, beware of health-care economists bearing statistics that prove the inevitability of their own solutions. I mistrust the fact that, while those people who work for commercial companies (rightly) have to declare their interests in writing in medical journals, those who work for governmental agencies do not do so: as if government agencies had not interests of their own, and worked only for the common good.

The one kind of reform that America should avoid is one that is imposed uniformly upon the whole country, with a vast central bureaucracy. No nation in the world is more fortunate than America in its suitability for testing various possible solutions. The federal government should concern itself very little in health care arrangements, and leave it almost entirely to the states. I don’t want to provoke a new war of secession but surely this is a matter of states’ rights. All judgment, said Doctor Johnson, is comparative; and while comparisons of systems as complex as those of health care are never definitive or indisputable, it is possible to make reasonable global judgments: that the French system is better than the British or Dutch, for example. Only dictators insist they know all the answers in advance of experience. Let 100 or, in the case of the U.S., 50 flowers bloom.

Selfishly, no doubt, I continue to measure the health-care system where I live by what I want for myself and those about me.

And what I want, at least for that part of my time that I spend in England, is to be a dog. I also want, wherever I am, the Americans to go on paying for the great majority of the world’s progress in medical research and technological innovation by the preposterous expense of their system: for it is a truth universally

acknowledged that American clinical research has long reigned supreme, so overall, the American health-care system must have been doing something right. The rest of the world soon adopts the progress, without the pain of having had to pay for it.

Theodore Dalrymple is the pen name of Anthony Daniels, a British physician.


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Healthcare Issue: Free Our Health Care NOW!

Please sign the petition and join those of us who are deeply concerned that a government run healthcare plan is NOT the solution to our healthcare problems.

Use the Action Pack http://actionpack.ncpa.org to sign the petition, to print the petition or to access our Learning/Teaching Tools about health care so that you can educate your friends, family and neighbors.

The current healthcare plan under discussion will cripple our economy with more debt and taxes, and it doesn’t even address what the vast majority of doctors believe is the most important piece of the problem–tort reform.

Below is a letter from the National Center for Policy Analysis, please sign the petition, spread the word, and share your thoughts.

 

Friends –

Thank you for your support of the “Free Our Health Care NOW!” petition. More than 870,000 Americans have joined you in saying “NO!” to the federal government becoming their health care provider. We now have a tremendous opportunity! The probable delay in the vote until September in Congress allows you to use the tools available below in “What can you do about this?” to educate everyone you know.

Your continued support is crucial in the fight against nationalized health care. In the last week, the proponents of nationalized health care have continued to champion legislation which will increase cost, limit choice and decrease quality of your health care. Please continue to tell your network, friends and family that government-run health care is a threat to the quality of their health.

The non-partisan Congressional Budget Office (CBO) estimates that ObamaCare will cost over $1 trillion. Notwithstanding President Obama’s promise to oppose legislation “if that reform adds even one dime to our deficit over the next decade,” the CBO estimates that recent House proposals will increase government spending by $1.04 trillion. Additionally, as for the Administration’s most recent cost-savings plan – to create an independent advisory council to set Medicare fees – the CBO concluded that “the probability is high that no savings would be realized”.

ObamaCare will dramatically reduce the choices you have over the cost and quality of your health insurance plan. Here’s how:

  • ObamaCare will create an artificial market called a Health Insurance Exchange. The mandates the Exchange imposes will reject plans that don’t ‘measure-up’ to the federal government’s expectations for health care plans. As a result, millions of Americans will be forced to abandon their current plans and to accept a plan that they do not want or need.
  • Additionally, ObamaCare will create a board of bureaucrats empowered to define which health benefits are “essential”. However, these “essential” benefits may exclude health care which most Americans and their doctors believe are essential – such as MRI scans and blood tests.

The bottom line: Under ObamaCare, Americans will face higher taxes and receive less take-home pay– all for a health insurance plan that forces them to pay for benefits they do not want and refuses to pay for procedures their doctor may recommend.

What can you do about this?

Thank you again for your support of the “Free Our Health Care NOW!” and for fighting against nationalized health care.

 

Jeanette Nordstrom
National Center for Policy Analysis
www.ncpa.org

 

Click here to support the National Center for Policy Analysis.

Click here to view the privacy statement

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Medical Myth #6 (example #2): Placebo’s don’t work

Here is our 2nd example from the medical literature regarding the power of the human mind to generate healing by placebo. Enjoy and share your thoughts with us.
Hippocrates’ Shadow: Secrets from the House of Medicine (David Newman):

“In the late 1930s, cardiac surgeons developed an innovative procedure to help those suffering from repeated chest pains due to severely blocked coronary arteries. The surgery consisted of making two incisions in the chest wall to tie off two unnecessary arteries that supply blood to the inside walls of the chest. Theoretically this could shunt extra blood flow back to the heart, thereby increasing flow through the hearts arteries and reducing chest pain. Initial reports indicated it was highly effective, and case studies showed success rates of up to 75 percent. For the next two decades the surgery became common, until the late 1950s, when two researchers studied the procedure separately and found strikingly similar results. The studies compared the surgery to a sham (placebo) procedure in which two incisions were made in the chest wall and then sutured without tying off the internal arteries. The studies showed the real surgery to be as successful as surgeons had believed. In the true surgery groups, 67 percent of patients showed major reductions in pain and in the need for medicine, and major improvements in the ability to exercise without serious chest pain. But the sham surgery was an even bigger hit: in the sham group 83 percent of patients showed the same improvements.”

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Flu Update

  • A very detailed article came out last week in the New England Journal of Medicine outlining the origins of the swine flu.  They have found that the swine flu is a 4th generation virus from the 1918 strain.  We are in a 90 year pandemic era all originating from 1918 strain, and finally,  “it appears that successive pandemics and pandemic-like events generally appear to be decreasing in severity over time. They say this is probably due to medical and public health advances.”
  • Another article points out that Tamiflu is not all that great and that rushing to be seen at the doctor’s office has contributed to the spread of this virus:

“The most puzzling, and most consistent, point of information in these algorithms was a recommendation to treat virtually everyone with antiviral medicines. The departments of health recommended that patients with even mild URI symptoms and virtually any history of any medical problem, or common contact with anyone who has a medical problem, be prescribed anti-influenza drugs.

On what evidence did the NYC DOH recommend prescription-only antiviral medications for all? Cochrane and other large-scale reviews show that oseltamivir and zanamivir reduce influenza symptoms by roughly one half day to a day compared to placebo, though only when given <48 hours after the illness begins. Unfortunately, the medicines frequently seem to add nausea, vomiting, or diarrhea, and cost roughly $100 per prescription. They also only work for those with test-confirmed influenza. The simple use of NSAIDs, it would seem, could rival these agents for symptom control, and without the side effects or cost.

With such a tepid, selective, symptom-only impact, and at such considerable expense, why use them? I asked my local infectious disease specialists this question. Treatment, they said, may reduce complications such as death, pneumonia, or hospitalization.

I looked further. Interestingly, despite the fact that 10,000-20,000 people typically die each year in the U.S. from influenza, antivirals have never been shown to decrease either mortality or critical illness. As for other complications, one meta-analysis of ten trials suggested small reductions in pneumonia and a 1% reduction in hospitalization. But the meta-analysis was retrospective, it used only cherry-picked secondary outcomes, and the studies were hand-selected from a Roche database. And yet this remains the only combined data ever to report any significant benefit on complications. Two much larger reviews have since concluded that the drugs have no appreciable effect on the use of relief medications or subsequent need for antibiotics. “

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Brown Widow Spiders

Who knew? We found a brown widow spider on the outside of our garage door AND we found one at our kids school!  So they are definitely out and about.  Be aware that when your kids are ‘hunting’ the huge orb spiders that come out in October every year that they could run into one of these.  Has anyone else seen these? brown-widow(link to article from Emegency Medicine Journal)

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healthcare Reform: Of NICE and men

I have not chimed in about the healthcare ‘crisis’ but here is a sobering article from Wall Street Journal pointing out the rationing of care that may occur under the changes that might be voted in.

An article in the Stanford Magazine in November of 2008 pointed out that:

1. over 70% of people were happy with their healthcare

2. CEO of Safeway thinks that we need to consider legislature to make people who smoke and who are overweight must pay more for their healthcare.  He experimented with such a plan within his organization.

3. California’s experience and H. Clinton’s attempts point to the issues not being resolved in one feld swoop, but only through slow incremental changes.