Wednesday, October 31, 2007
This brings up some interesting issues regarding womens' right to contraception. Much of the debate has been colored by gender and racial considerations that emerge from a larger social context (old white man controlling the fertility of a young woman of color for example), but I would prefer to stick to individual ethics
In the US, the government has no constitutional authority to impel behavior from individuals, especially if it is morally repugnant to the individual, unless there is a compelling societal interest. I am not sure Europe's constitutional protection of the individual is as strong as the American tradition.
On one side of the argument is the moral question of abortion which appears to coincide with the protection of individual liberties.
On the other side of the argument is a woman's liberty in relation to reproductive choice and the practical issues of access to heath care.
I used to work with physicians who actively advised against abortion, the use of abortifascients and did not prescribe contraceptives. I respected their right to do so and they respected my wish to do the contrary. If a patient came into the office with the expectation of having her demand satisfied, she was in for a sad surprise with some doctors.
Is it reasonable to demand that a health care provider simply agree to whatever a customer/client/patient wishes? I think not, especially if there is a moral overlay. We should all try to do what we believe is best, given our ability to discern the correct course of action. As a medical director, I might hesitate to hire a physician if they refused to provide a service that was required or needed by the community, from either a business or a public health perspective. But on the other hand, if they cannot abide by the perspectives of my organization, they can certainly set up their own shop where they please and not have to deal with me and my beliefs.
They should not be expected to dispense something for which they harbor doubt, medical, ethical or otherwise. So maybe the expectation of getting your morning-after pill on demand, wherever and whenever you choose is unreasonable. Access is one thing, but not at the price of the individual liberties of my colleagues.
The government is really very good at distributing cash, with only the normal deadweight loss attendant on taxation. But it is an abysmal dispenser of advice on how to live your life, which is why the Declaration of Independance promises not happiness, but only the space to pursue same. I'm very open to arguments that private charity can't cover the cash needs of the poor, but I'll pit a private institution against the government in the "better living through social work" game any day of the week, and twice on the last day of the month.Obviously, I'm against most forms of government help for adults, but is there anything as creepy as the notion that the government is supposed to improve you?
This sounds a lot like the description of medical paternalism we heard about in ethics class in first year medical school. Of course we don't want other people (physicians or government agencies) making decisions for individuals.
On the other hand, the counter-argument seems embedded in Ms. McArdle's blog's name. Asymetrical Information is, in this instance, an information deficit, which capital markets assume are part of making the market and thus part of the playing field. If health care is different than other markets (and I don't know that it really is, I will just posit...), then it is here we must look.
A lady in a fur coat passes a homeless man in a sweatshirt on bitter cold New York night, and she is certain he will just spend it on drugs.
If the man has made poor decisions in his life, then he must be held accountable and live or die tonight by his decisions. On the other hand, if he is mentally ill, perhaps a schizophrenic, does have the capacity to make good decisions. Often the delusions and hallucinations that schizophrenics suffer can create the very suspicions that lead them to stop their medications. Can this man be held accountable for his poor decision despite an illness that guarantees his inability to make the decision? Why is this any different than other psychological dynamics that lead to bad decisions?
If this man tends to make bad decisions and he is given money by a government bent on helping people non-paternalistically, will purveyors of health care (or any other product) not swoop in to sell the man things he doesn't need? After all, the markets have their own natural incentives, not the least of which is the single-minded pursuit of capital and profit.
The crux of the matter is that the homeless man generally suffers from a deficit of information (asymmetrical information) and is forced to take someone's advice. So whose advice? Advice from government is probably a little too paternalistic; there are better things to do with my tax money. But what are the alternatives? Advice from the insurance industry? Advice from hospitals, whose financial survival is dependent on selling technology and procedures? At least physicians have the Hippocratic Oath, but this increasingly marginalized when we are encouraged to be entrepreneurial.
Maybe government needs to be part of the solution, but my own principles and ideology would argue that it has be sparingly, carefully and minimally.
Tuesday, October 30, 2007
The breadth of interests could range from physicians writing (Arthur Conan Doyle), stories from clinic (William Carlos Williams), medical essays (Oliver Sacks). In addition, I was reminded of the role of such art in teaching students and to some extent in healing.
Kudos to Paul Levy for focusing on the human side.
Running a hospital: Grand Rounds Volume 4, Number 6
Monday, October 29, 2007
First, the recommendations, to be published in November, appear to be centered on the developmental exam. Is it really screening, if it is part of the routine exam? Our purpose with the frequent schedule of visits is to pick up any number of abnormalities, many of which do not really qualify as screening, in the usual sense. Screening, as a term, should be reserved for specific testing for specific conditions.
Symptoms that raise concern include not smiling at the sound of a parent's voice by the age of 4 months and the loss of language or social skills at any age. These are non-specific, that is, although they are common in autistic children, there are other causes and may be normal in non-autistic children. Babies who don't babble by 9 months or point by 1 year may have other developmental problems, or in fact, none at all.
Rigorous assessment of a screening recommendation also needs to identify certain statistical properties of the test. Most physicians are familiar with the concept of sensitivity and specificity, but once loosed on an unsuspecting world, the predictive value of a test is more important. It's not about what proportion you will miss, or what proportion of your patients has another condition. It is about how often your positive is really positive and how often it is simply wrong.
We never argue the benefit of a timely diagnosis, but doesn't the cost of positive screen for something as emotionally charged as autism make it seem at least the slightest bit unwise? Not to mention that, in fact, treatment is poor. The possibility that early intervention improves outcomes is not based on hugely significant outcomes. As a parent, you're still stuck with an autistic kid; you just knew about it a little sooner.
In the absence of definitive and significant evidence of the cost-effectiveness of an intervention, there should be no screening. I am afraid that the cost of false positive simply outweigh any potential benefit.
The fact is, we still examine children regularly and attempt to detect developmental delays including autism as soon as we can. My problem is that they are calling it a screening test, which it is not. My problem is they will unleash this concept on an unsuspecting public with little apparent consideration from the rest of the medical community. It was published in the Washington Post before a medical journal. Poor form, but then, who cares, right? It's all entertainment anyway.
Some innocents commenting on the WSJ blog are wondering if the FBI would raid someone's office without cause. Others suggest the FBI would do anything if it could improve their image.
Investor lawsuits are already flying, the stock is down nearly 75% and a lot of people at WellCare are asking themselves why they took the job in the first place.
Several years ago, Medicaid fraud investigations were reorganized under state control. It has become a lucrative business, not just for government. Instances of Medicaid fraud typically do not revolve around billing for a made up patient or non-existent procedure, but rather, systems which support consistent error. Fraud and error are one and the same, except that error becomes fraud once it is built in to how you do business.
Many physicians have mis-coded their visits. The difference between a 99213 and a 99214 in outpatient care is miniscule, but reimbursement is 20 - 30% different in most out-patient settings. One physician who went to jail for fraud had an office so messy he couldn't even find charts to prove he had rendered any services. Half of his charts were under a couch at home, where he had brought them to finish his documentation.
A medical supply company that got into trouble supplied wheelchairs and other equipment for patients and billed Medicare. However, there were occasions they tried to help the patients out and supplied the equipment (and billed) before getting a physicians' authorization. I can't remember if anyone went to jail, but it sure blew up on those guys.
Insurance companies of all stripes, in health care or otherwise, have a simple natural incentive: attract clients and find a way not to pay claims. Of course, they cannot do this overtly because no one would trust them to do business. The long-term integrity of their $2.2 trillion business trades off with short-term financial considerations.
All physicians know how health insurers play at the edge of the law. They take so long credential some of my docs, that they later told us the signatures no longer carried legal weight because it was too old. They tell us it was our fault, even when the application was clean. Same with charges. I am aware of a hospital that had a charge go back and forth for so long, once it all got sorted out, someone at the insurance company stepped in and said it was their policy not to pay for claims made more than a year ago. It seems like a game and the insurers typically have the information and power to squeeze the providers.
I do not have any inside knowledge of what is happening at WellCare, but have enough understanding of the wiggle room and gray zones that can be abused, I would guess WellCare tripped over something really simple. Their Medicaid profits went from below average to 200 basis points above average between 2004 and 2006 according to a Lehman analysis released to brokerage clients this morning. WellCare's overall margins are well above peers. Performance in a mundane industry like insurance does not improve so dramatically unless something fundamental happened. No, it's not that they run their business so efficiently.
I hope WellCare's not in your retirement fund.
Friday, October 26, 2007
Sometimes I regret what I wrote and I have addressed that in the comments rather than delete what I know some people have read.
Sometimes I suffer from the 'debater's curse' and think of a better way to put it afterwards.
All this to say that I absolutely hate the last post's title, but I won't change it because I think that is part of the essence of blogging.
We can rant, we can collect links on a specific subject, we can run linkfests on no particular topic and it's OK. Too many edits would ruin the immediacy and freshness of commentary.
Once in awhile, we put together a good essay, a well-structured well-thought-out point or a short story or vignette. On these occasions, bloggers reach literary heights without the pretensions that would accompany a self-conscious effort.
This week I would like to commend the work of:
- Panda Bear; Res Ipsa Loquitur (a better constructed take on alternative medicine, similar to my rant on a poll that came from a University research group looking into the use of CAM for under-served populations...)
- SurgeonsBlog; Sissy Too funny! A story about finding an unexpected... well read it. (Sid's rant on immigration later on in the week bears honorable mention.)
- Dr. Hebert's Medical Gumbo; Privy We are often involved with intimate bits and parts. It's nice to see a humane and dignified story such as this. (2nd week in a row)
On an unrelated topic, The Agonist points to the words of Sun Tzu, who wrote The Art of War, 1000 years ago.
- If the campaign is protracted, the resources of the State will not be equal to the strain.
- Now, when your weapons are dulled, your ardor damped, your strength exhausted and your treasure spent, other chieftains will spring up to take advantage of your extremity. Then no man, however wise, will be able to avert the consequences that must ensue.
- Thus, though we have heard of stupid haste in war, cleverness has never been seen associated with long delays.
- There is no instance of a country having benefited from prolonged warfare.
We appear to be in a long-standing war where consumers, government, physicians, hospitals, big pharma, insurers and other business interests are working at cross-purposes and throwing money at so many problems, no one remembers what we are trying to accomplish any more. This war has damaged all the players.
And a presidential candidate shows that he knows nothing about health care. Nobody likes insurance companies and their ploys for not paying legitimate and correctly completed claims. But the alternative is a single government payer, which has considerable opposition. So here's a logical strategy: threaten to abolish private insurance. Since the health insurance industry is one of the largest money and power centers in US health care, the threat to obliterate them will probably create some opposition from the insurance industry.
He may get into the news with a proposal like this, but Kucinic is toast. Moreover, his proposal confirms that the entire discourse on health care is devoid of reason, strategic approaches or critical critical thinking. And we are very obviously in decline due to our incapacity to prioritize amongst our many wars.
Wednesday, October 24, 2007
The news broke this morning, with Reuters publishing a brief article within minutes of the coffee break. At the quarterly meeting of the Advisory Committee on Immunization Practices (ACIP), the first order of business was discussing nasal flu vaccine.
The best explanation I have found so far is the Post’s HealthDay article, but the fact is, we may have to wait for the ACIP Minutes before we really know the exact reasons why. Having said that, it seems that a price reduction to $18 (it used to be over $70) and some good safety studies down to the age of 2, not to mention the obvious absence of a needle, has put MedImmune in the position of a significant profit potential. The news was overshadowed by parent company’s Astra-Zeneca losing a key patent today. Keep your eyes on the stock.
See what happens when you do the right thing?
They are polling Federally Qualified Health Centers about their use of complementary and alternative medicine (CAM; a term invented to lend credibility to the unfortunate use of unproven health-related interventions.)
Now hold on a cotton-picking second! I have trouble getting people with gallstones their surgery until they have ascending cholangitis, a potentially lethal complication. I find myself working with radiologists to dose radioactive iodine for severely hyperthyroid patients, because there is no endocrinologist available who accepts Medicaid. I have to bend backwards trying to do the best for patients who can't afford basic investigation, and what do you want me to do? You want to find out how often I get them to waste their money on fish oil, black cohosh and star energy?
Dr. Weil, you sure have balls.
I think the argument goes that scientific medicine in the 20th century has gone too far from its traditional healing roots. If there are health disparities amongst under-served populations, then there must be disparities in access to CAM. Many of the under-served are already using complementary and herbal remedies, so we need to better understand them.
But there is a major problem with the argument. CAM is a luxury related to well-being, as defined by the best possible physical, social and psychological functioning. Public Health, while it recognizes the importance of social contributors to overall health status, is most interested in ensuring access to basic health care, prevention, primary care, immunizations and the like.
To waste and divert resources from this population with self-serving, self-promoting clap-trap that will end up exacerbating the health of the most vulnerable. CAM has its place with middle and high income individuals who are seeking to maximize aspects of their life and are willing to go well beyond what the evidence base support. "You pays the money, you takes the chance..." But in the case of under-served populations, such efforts will only further sabotage the required efforts to provide improved health care access for the poorest of our compatriots.
Professor Stern at InsureBlog, would you care to weigh in on what a mandate for covering CAM would do to insurance rates?
Dr. Osler is turning in his grave.
This time it's a physician's daughter who went to an ER in Virginia. The CT scan alone was billed at $6500, instead of the $600 (my guess) the hospital usually collects from most insurances. I say that because the cash discount at a local outpatient radiology is under $400 for uninsured patients.
The addition of contrast (I think I saw on the video that the CT was billed with contrast, but I'm not sure) would raise the cost by another $100 or so, for each of the abdominal and pelvic scans.
Scanning two areas of the body scan at the same time should be billed separately but the second is supposed to be discounted to the tune of 1/3 to 2/3 in recognition of the fact that it takes fewer resources.
The story is about defensive medicine suggests a $1400 ultrasound would have done fine, rather than the more expensive option of a CT. Personally, I think the lost art of physical examination, treatment and a visit in a week would have worked best. The meds at a $20 copay (or less, with generics) and the 2nd visit are pretty inexpensive in comparison, even if one considers the potential for lost wages and parking!
But wait! Did someone say $1400 for an ultrasound? For a pelvic ultrasound? The Medicaid fee schedule in our state puts an ultrasound around $100; that would be our cash rate for the uninsured.
Here's the thing, nobody likes the Medicaid rate. It's much too low. The disincentive for doing procedures would be pretty evident at that price, but then, why would a hospital buy a machine without a decent ROI? Why would a company improve the technology without the potential to recoup its investment? Our radiologists look at Medicaid as their charity work, which actually makes it harder for a clinic like hours, where a third of our patients don't even have basic state medical assistance. It's a little like a medical version of "I gave at the office."
So where did $1400 come from?
Tuesday, October 23, 2007
I had an interesting conversation with a patient who was charged $2800 for a period of hospital observation, less than 24 hours, related to an episode of chest pain.
The "rule-out" is becoming a profit center for many hospitals, especially the ones that figure out how to turn it into an efficient assembly line. I'm not sure how much the average collection (or adjusted charge) is at most hospitals for a "chest pain, rule-out MI" observation not resulting in a hospitalization, but my guess is less than $1000.
Of course this fellow was uninsured and, despairing at the price, ignored the bill. Now his credit is at risk and the collections folks called a couple of days before I saw him for an unrelated problem. He had tears in is eyes as he described how badly he wanted to pay his bill.
So how's that for an irony? Hospital charges ridiculous price in part to compensate for uncompensated care... patient shrugs it off as an impossible sum to even address... hospital collects next to nothing where they may have collected at least enough to cover some costs.
I've said it before, I'll say it again. Medicine and the health care business is both a calling and a social good on one hand and a business and an economic engine on the other. I did not take my management degree at an MBA school because it is not often clear to the students that sometimes the goal is not unfettered pursuit of profit, it is single-minded pursuit of mission.
I suggested he call the hospital and explain his situation. I fully expect they will accept the two or three hundred he can afford to pay, and when you think about the role of a not-for-profit hospital in the community, that's pretty fair, all around.
Monday, October 22, 2007
I have to think differently than the average doctor in a private office. I have to be concerned that we see patients with infectious diseases and our employees can pick up infections at work and disseminate them at home and in the community. I have to tell them they can't wear open-toed shoes or sandals in the office, although I sometimes wonder if I wouldn’t be more comfortable myself. I cannot afford to undermine "the man", when I am "the man"... I think??!
I have to make sure my employees have not been exposed to tuberculosis and that they are immune to hepatitis before they start to work. I write and enforce the policies that demonstrate to licensing and accrediting bodies that the company does everything it can to assure a safe workplace. Boy, do I write a lot of policies!
But we are also a not-for-profit on a shoestring budget and need to conserve money. When I came to this company, I discovered we were doing quantitative Hepatitis B titers. I was surprised, since I thought there was no reason to spend so much more money than the qualitative test, which gives you a straight yes/no answer. The question is simple; "does the employee have enough antibodies to be protected against Hepatitis B."
My colleagues at this new job decided to investigate. We discovered that the reason we were doing quantitative tests was because of a CDC guideline that specified the antibody level at which someone was immune. Health care workers must have titers greater than ten or be re vaccinated.
Persons who do not respond to the primary vaccine series (i.e., anti-HBs <10 mIU/mL) should complete a second 3-dose vaccine series or be evaluated to determine if they are HBsAg-positive.
How can you know the titer if you don't do a quantitative test? Right? Well, maybe someone should have asked, as my staffer did, what the cutoff is for the qualitative test? Sure enough, the qualitative test is positive 19 times out of twenty if the titer is greater than 10. As I write this, although I asked about the reliability of the cutoff for the qualitative test, we should have asked the same of the quant. There is no guarantee that because a test gives you a more specific number, that it is necessarily more accurate. The WHO studied the accuracy of various commercially-available tests and found many to be even more accurate than the one our contract lab uses, but we only need a cutoff of 10. [If you read the WHO article, be aware that the units don't match...]
So a myth had been circulating that the Joint Commission was requiring quantitative hepatitis B testing. No more than a myth, it turns out, since the Joint Commission requires best practices and adherence to stated policies. They do not usually express specific requirements, except where they are plain obvious. In this case, a long chain of logic with a single simple flaw pushed us to do the more expensive quantitative test when the cheaper and simpler qualitative test met all our objectives. A re-examination revealed that we could save several hundred dollars a year and protect our employees to the level of best practices and national -- nay, international -- standards require.
[Minor edits have been made for clarity, due to worthy comments from my better half. The orginal post was published about 1 PM, this one about 11 PM.]
Sunday, October 21, 2007
This is The Physician Executive Primer on MRSA [thanks to Kevin, MD for the nod and one additional reference that I have added into this post.].
First, the organism is known a staphylococcus aureus. It is an old bacterium, as old as the rocks , having come to light in the late 19th century. It has a predilection for living in nasal passages and is frequently found in skin. It is not a universal pathogen, often living as commensal in many human superfices. Since the skin can be thought of as the largest organ in the human body, it makes sense that staphylocci are the most common organisms that live side by side with humans, not causing disease. E. Coli, naturally inhabiting the gut, is another sometimes-pathogen, that usually keeps harmlessly to itself, if basic hygienic practices are in effect.
Truth be told, other staphylococcus species are more common on human skin. These almost never cause disease. S. Aureus is a little more frequently pathogenic.
The key point here is that staph can cause disease in some people and not in others. The other factor in its virulence is the severity of the disease it has the potential to cause. One may wonder why it lives causing no harm in one person and causes a life-threatening disease in another, you have put your finger on the great unknowns in medicine, although much progress has been made. It still looks random to me.
I once had a friend who got nasty skin infection as she was failing out of premed. The stress of not doing well in school and seeing a relationship break-up along with the usual parental pressures, weakened her in ways that sound cheezy if spoken in medical circles. Shaving her legs provided the gateway to the bacteria (some would call the skin the most important component of the immune system.)
Some staph causes invasive disease, getting well past skin structures and being potentially lethal. In general that would be a function of a gene carried by the invasive bacteria. We always had effective antibiotics, but now the bacteria is becoming more and more resistant. Penicillin once worked, but that drug became ineffective early in the antibiotic era and methicillin was developed to counter the bacteria's first attempt at inactivating our drugs. Now Staph has evolved resistance to methicillin and many other anitbiotics. Although not a formal characterization of staph, physicians have been known to refer to "multiply drug resistant staph."
It turns out the genes for invasiveness and resistance now co-exist in a new strain of staph.
Antibiotics become resistant to the antibiotics that are used to kill it. The more the use of a given antibiotic, the greater the resistance. Some of that resistance wears off when an antibiotic falls into disuse from ineffectiveness.
Basic cleanliness is critically important for the spread of pathogens in hospitals. Since antibiotics are most frequently used for the critically ill in hospitals, it is no surprise that resistance first appeared in hospitals and is increasingly spilling into the community. Anywhere people live, work and play in close proximity to each other will be the first areas of concern. The same pattern will follow with skin infections with other skin bacteria as they become more resistant.
Genetic change in bacteria occurs faster than people, given a generation time measured in minutes to hours. Doubling time for E. Coli is usually about 20 minutes. The question everyone should ask is "has the bacteria changed?"
Here is the best answer available from the CDC so far:
To date, most MRSA strains isolated from patients with [community-acquired-MRSA] infections have been microbiologically distinct from those endemic in healthcare settings, suggesting that some of these strains may have arisin de novo in the community via acquisition of methicillin resistance genes by established methicillin-susceptible S. aureus strains.So it seems staph has acquired the ability to invade, resist antibiotics and cause epidemics in the community, all at the same time. This is a problem, but it is not the only one: VRE (vancomycin-resistant enteroccus), and MDR-GB (multiply drug resistant gram negative bacilli) are already major problems in hospitals and long-term care facilities. Even worse, some strains of streptococci are becoming resistant, one of my old profs worst nightmares come true. And it's not covered in the current vaccine.
Basic hygiene, using antibiotics only when necessary (which means getting them out of the food supply) and a lot of bench research is what will get us out of this mess. Physicians can be a little more firm in saying no for conditions (like simple bronchitis associated with colds) that should get better without antibiotics and patients should not regard drugs as panaceas. Drug companies should also be careful how they market, lest a few marginal physicians exacerbate an already spreading problem.
The alternative is returning to pre-antibiotic rates of infection mortality. And that's really scary.
The good news is that reducing the use of antibiotics is slowly followed by a decline in resistance as the strategies of treating infections with cycling antibiotics or multi-drug regimens has been shown to reduce resistance rates.
TB is an even scarier problem, but the subject of another blog post, some other day. Maybe.
Saturday, October 20, 2007
A duo of articles at the NYT looks at institutional efforts and mothers' concerns about the proposed FDA ban.
Pediatric cold medicines were approved in the early 1970s despite almost no evidence that they worked because regulators assumed then that drugs that worked in adults would also be helpful in children. Since then, researchers have learned that adults and children can react to medicines very differently.Effectiveness has to be considered in the context of a claim of efficacy. Decongestants decongest. Acetaminophen reduces fever and pain. Antihistamine... well, they make people sleepy and that's probably the main reason they are so popular. A little rest, a little relief, a good night's sleep...
What cold medicines don't do is fix the cold. They do not reduce the duration. They do not reduce the risk of complications (like ear infections). They do not reduce the overall severity of the cold.
The best advice with a cold medicine is not to take it regularly. It is not an antibiotic and the expectation needs to be tempered with a dose of realism. Do not date the medication exactly every four hours or six hours or twelve hours. Your doctor probably said "as needed," that means go ahead when you are really miserable and desperate for relief. It does not mean, "just in case it gets worse overnight." Just ask, OK?
So being peevish about efficacy revolves around what you're trying to accomplish with the medication. The FDA is right in saying cold medicines are ineffective in reducing the duration or severity of the condition. But cold medicines are effective at reducing symptoms, which was the original intent of cold medicines, naturally taken advantage of and stretched by manufacturers.
People should treat all medications with the utmost respect and only take them when absolutely necessary. One mother quoted by the NYT kind of had it right...
“Oh, I’ll probably ignore [the ban],” Ms. Frank said, speaking over the cacophony of a four-children-in-a-brownstone play date that sounded more like New Year’s Eve on Times Square. “It’s miserable if they can’t sleep. So I’m afraid I’d use it, regardless. But sparingly. And if they were babies, I’d hesitate.”The demand to help parents whose kids are sick is not going away. Maybe education and limits on inappropriate marketing by manufacturers would work better.
But the problem is that the FDA appears to be looking for the best arguments to put forward in anticipation of the amount of resistance they will face. When they stoop to an irrelevant misrepresentation about the lack of efficacy (symptom versus condition), it probably means they are facing a really big fight. Maybe there are bigger fish to fry for the FDA? Why use the weighty force of government rather than an education campaign?
Friday, October 19, 2007
Much of my action this week was off-site, at InsureBlog. They were under a lot of pressure this week having attracted the adulation of the right and the ire of the left over the Graeme Frost story. My comments were taken in the spirit of the left, and I escalated. I let it escalate like a school yard fight, but cooler heads prevailed off-line.
Henry Stern and I have decided to bury the hatchet. I can stand having a different ideological position as another, but ask that the discussion be more substantive. The constant right versus left confrontation is boring. Escalatory provocation works sometimes, but I wouldn't want to rely on it regularly.
Suffice it to say, I shall refrain from gratuitous derogations in the future, as long as the views of both sides are well-aired and nobody's lumping me in with one side or the other.
As has become my habit, I pick three posts that are the most literate each week.
- Val Jones tells the tale of her friend with cancer, Unencumbered by Prognosis. It is a very short story full of pathos, the joy of life and the atmosphere of William Carlos Williams.
- Dr. Rob does a great job again this week with a duo of stories, one so short that I'll combine them into one entry this week: Indoctrination and The Dangly Thing. Why did I pick these two out of an exceptionally Distractible week? Well, Indoctrination had the feel of one of those office short stories (I'm bringing up William Carlos Williams again) and the Dangly Thing elevates a blog post to the level of a comic essay, I would almost expect to see in The New Yorker or Harper's.
- A week without Maria is an unintuitive week. Shoes is another amazing vignette that could pass for either essay or fiction. Either way, intueri is a great blog and I'm starting to feel like a groupie.
This is a thought exercise, so let's take it one step further. What if the vertical axis represented value and not numbers of people. What if the overall utilitarian value for a society peaked somewhere in the center? There is no reason to believe this is necessarily true and certainly no way of generating data to support or refute this argument, so this becomes a classic liberal arts proposition inviting arguments for pro and con, which are judged on the quality and integrity of the argument.
Let's look at SCHIP:
The right refutes the need, denies the existence of uninsured, points to their poor choices invoking the doctrine of personal responsibility (they screwed up, we're not bailing the out) and points to the abuse (as though a single instance of abuse, even if valid, were reason enough to dismantle the entire initiative.)
The left expands the need, demands help as an entitlement, is dismayed when natural incentives in open markets sabotage their best efforts and froth at the mouth to the point that they lose their moral high ground.
Yesterday's tirade by Pete Stark is an inexcusable descent into the worst form of political rhetoric. No matter what you may think of our lame President, the argument is that we can afford some health care coverage, given the obscene amounts we spend in Iraq. That children's heads are blown off for the President's amusement is beyond the pale.
More to the point, Pete Stark is the father of some knee-jerk regulation (Stark Law) that has been sadly ineffective at curbing the profit motive by inhibiting partnerships between hospitals and physicians). This is the kind of structuralist thinking that has gone by the wayside in the post-modern age, even as conservatives abuse the relativism inherent in it.
OK, I lost you. Sorry. Stark is just out of touch.
Look at the interview of David Hyman in Managed Healthcare Executive. It is smart, although not entirely accurate. Briefly
- Small employers who are already providing coverage do so out of self-interest [i.e., the desire to retain valued employees]. It is unlikely that the Massachusetts health plan substantially changes the dynamics of that decision, particularly given the modest carrots and sticks at stake. Some employers may switch insurance, others will not. On balance what happens on the margin can affect the balance of good created over time. Only patience will tell.
- If you start from the premise that people should only have 'good' plans as defined from an upper-middle-class perspective, you've simply assumed away the financial constraints that most of the population operates under.
It represents conservative thought at its best, albeit from Cato's libertarian perspective. Contrast that with Michael Cannon's Op-Ed at NRO (it appeared there for a day or so, I can only find it at the Cato site today). He said it was the most fun he's had writing an Op-Ed. I stopped reading at the liberal versus conservative blah blah blah.
As anyone who has read about the Prisoner's Dilemma, overall value in a non-zero-sum game is greatest with about as much collaboration as confrontation. In other words, somewhere in the center.
And Pelosi's right about Armenia and saving SCHIP.
Thursday, October 18, 2007
We might find out soon. An interesting coalition of business, health care and consumer interests are pushing the medical homes agenda. It sounds a lot better than gatekeeper and might even work, if we are regarded as patient advocates instead of an obstacle to utilization.
More information on The Patient Centered Primary Care Collaborative can be found here (registration required).
Wednesday, October 17, 2007
In a nutshell, MRSA is not caused by dirty schools that need to be cleaned up or dirty people that need to be avoided. Our society is already sufficiently phobic of bacteria and being overly fastidious in cleanliness can harm the skin. Staph Aureus is a natural denizen of the skin and its resistant version is merely a function of antibiotic overuse.
But in the economic model, medications must be marketed to consumers. Differentiation is a basic principle of marketing, in order to demonstrate how the new drug is better, more powerful, will somehow improve virility or desirability or financial power. (I know it's a stretch for an antibiotic, but as the marketer would say, "we're selling a lifestyle.")
Thus the incentive is to use more, not less antibiotics, and to use newer ones, not older models even if they are more trustworthy. If we tell consumers not to consume antibiotics, we would be curtailing an engine of economic growth and playing into the "nanny state," which would have the government tell us what to do.
But the outcome is a horribly resistant bacterium that should normally cause no more than a bad zit and only rarely any condition requiring the use of an antibiotic.
A mom with a newborn recently showed up in clinic with a copy of the newborn's hospital examination, as is customary for our locality. I noticed, buried in the usual neonatologist scrawl a note that read "melanocytic patches on sacrum, AKA Mongolian spots."
These dark patches on the proverbial baby's butt are more common in people of color, especially Asians and North American aboriginals. How they ever came to be associated with Mongolia, I do not know.
Numerous other names exist, some with an ethnic tone, like the Semitic streak. But apparently, there is anthropological descriptor know as Mongoloid race, which includes people of East Asian, Polynesian, Indonesian and Micronesian descent. Mongolian spots are reported to occur at 90% frequency in this group.
I wish I knew why this pediatrician elected to document choosing those words. Was it political correctness in face of an ethnic characterization? One thing for certain, the use of the term always raises eyebrows amongst lay people, especially the social workers to whom you end up having to explain this lesion to. Is 'melanocytic patch' or 'macule' any clearer to the lay population?
I was personally involved in a circumstance where a child was removed from their parents' custody over a weekend for abuse. Our group received notice Monday morning and, fearing the worst, went straight to the chart. Thank God that someone was thorough enough to document the presence of the spot, so common amongst our patients, I confess, I sometimes just forget to write it down.
"Yes ma'am, it's a birthmark. No, I don't think it's a bruise if he was born with it. Yes, it seems to be the same place you describe the bruise. It should fade in a few years, usually by the time they child is six or seven. No, it can't be a bruise if it's been there so many weeks already."
Tuesday, October 16, 2007
No, I am not a masochist, I was a family practice residency faculty.
Given the intense turf wars caused by an oversupply of underpaid specialists, it was an unpleasant environment to work. The concentration of specialty providers in big cities and urban areas poses some problems when it comes to costs. Frequently, one looks to mid-levels as a way of addressing problems in health care. Indeed Physician Assistants and Nurse Practitioners have a potentially important role to play in health care, but where?
Jason Shafrin at the Health Economist takes a look at midwives (included in the ranks of nurse practitioners for most of the latter part of the past century.)
I like midlevel providers like nurse practitioners and physician assistants because of their ability to bolster the ranks of primary care, the main engine of cost containment in health care. They can be invaluable in rural areas where it is difficult to entice specialists, even where there is a critical mass of demand for their services.
On the other hand, Jason's post appears to be looking at midwives as a less costly alternative to obstetricians. A commenter on my site reminded me of Milton Friedman's assertion that licensing leads to higher costs without assuring quality. In medicine, we have established a complicated and lengthy licensing process in the secure belief that the alternative was the chaos of snake-oil salesman that populated the United States at the turn of the last century. In other words, there was a compelling societal reason to limit and license people delivering health care.
I'm not sure what we accomplish by looking at mid levels as alternatives to established specialty providers. Moreover, specialists and midwives are equally maldistributed, being over-represented in metropolitan areas, where competition finds a way of increasing costs. Yes, health care acts strangely and higher concentrations of specialists tends to increase costs rather than reduce prices as one would expect.
On the other hand, finding an incentive to better distribute physicians may be a subtle way of improving physician incomes and health outcomes and reduce costs.
I want to make it clear once again, this is not a tirade against nurses or midwives. Nurses have saved my backside too often not to be collaborative and old school midwives working in labor and delivery taught me everything I know about delivering a baby.
I am questioning how we make policy in the face of a web of data and mess of potential starting points from which to approach the data.
Monday, October 15, 2007
Hmm, sounds like primary care, I thought.
A few disclosures and acknowledgments; I am not an economist, taking a class in a public health school just doesn't cut it. I've played with the markets for years and have a passing familiarity with concepts related to valuation and one of the reasons I am more comfortable in the US than Canada. Markets work better at determining value than governments do.
So if a provider of a service can be somehow valued in terms of the assumption of risk, most primary care physicians work in a generally low-risk environment. Every service provided by a procedural specialist may represent a greater absolute reduction in risk. But risk is also additive, so the total amount of risk assumed by a primary care physician could be greater if considering the proportion of the population that requires the service.
One of the reasons that primary care physicians are generally paid so much less than procedural specialists is the shortness of supply for those skills. In a consumerist society, we seek rare and unusual skills and pay a premium. The perception of risk can be influenced by so many factors that cannot be scientifically objectified.
Maybe the market for various specialties is working as intended, but primary care is not using its leverage. Using leverage on referrals and denying approvals for emergencies that did not go through primary care may seem as repugnant to others as it does to me, but it is merely the most obvious level of leverage we have. It's what the insurance companies expect of us, because we are the primary risk reduction tool for them.
Maybe structural incentives need to be realigned so that we are expected to respond to the patient's perception of risk and not the perception of other stakeholders.
Maybe I just need to go back for a PhD.
- Fox News article on how dieting children end up gaining weight. This should surprise no one who treats obesity, since dieting is generally avoided in children and adolescents for fear of the double-edged sword of malnutrition and obesity which can co-exist when one's overall intake is out of balance. Full research to be published in November Preventive Medicine.
- Med Journal Watch blog post on a study that indicates dieting messages don't work. Not a surprise, since over-eating does not seem to be the principal deciding factor underlying obesity. Healthy eating behaviors (a term used by the authors of the study which appears to perplex the authors of the blog), including how we eat (social, solo, environment and context, binging etc) and what we eat (appropriate balance of high fat, high carb and high protein foods, since no food is inherently unhealthy, except maybe that chocolate-hazelnut spread from Europe I love so much...) and how we exercise (affected by length of commute, built environment and food choices in our neighborhoods) all affect weight. Obesity is a lifestyle disease and there are just too many enticements to being unhealthy and too few incentives to being healthy.
- Original research that points to the disappointing failure of a New Zealand program targeting obesity in schools. The fact is that, even when we correctly identify the causes of a problem, that does not represent evidence that an intervention will work. School-based interventions for obesity have been producing contradictory results for over a decade and we still can't figure out what components are important and what components can be discarded. Evidence suggests that exercise counseling and basic nutrition education must coexist to work well. It seems to me that the CHOPPS study focussed disproportionately on soda consumption. [Via MDLinx]
- One final piece of research that indicates how the interaction of genetics and the intra-uterine environment can cause problems with carbohydrate metabolism into childhood and beyond. Epidemiology is a powerful tool for approximating truth, but bench research will need to become integrated with community based interventions to address complex problems like obesity. [Also via MDLinx]
Cancer death rates are decreasing unabated. It appears that cancer care has reached an important tipping point, an effect of both prevention (e.g. colon cancer screening) and treatment.
There is one cloud about the data, which is a data collection problem and a good argument for minimizing bureaucratic involvement in health care.
The VA's participation in national cancer surveillance, on which this morning's story is based, has come into doubt. As far as I can tell, reading between the lines, this is based on a sad misreading of HIPAA's confidentiality provisions. We must accept the existence of a bureaucracy, as well as the fact that it is a living organism that must assure its own survival.
The VA has a long history of providing poor quality care at bloated cost with a huge administrative overhead and bureaucratic mucking about. What better way to hide it by hiding your outcomes and blaming a law whose intent never extended to public health registries. Hopefully the states have the power to compel the VA to participate in registries.
The absence of VA patients would be expected to lower cancer incidence but raise survival. Since the registry data is supposed to be published later today, I cannot yet tell if VA patients are included in the most recent report, but knowing the lead time required to analyze this type of data, I think we are probably dealing with data unadulterated by bureaucratic meddling.
So overall, good news. The profit motive in medicine, while causing significant unanticipated problems (costs, insurance etc.), has been able to deliver some significant improvements in survival, lifespan and quality of life.
The question she poses is "When should taxpayers pick up the tab?" I don't know the answer and I can't tell if there is an answer in Ms. Emrich's post, but it is an uncommonly accurate description of the plight of many patients. A case worker could scarcely have done better. This nation must recognize the need, define the level at which we can afford to intervene and then act to expand coverage responsibly.
While some would have us believe that families like Graeme Frost's are in a straightforward and affordable position, given current benefits levels, I would argue otherwise. Patients need more help, not less. The SCHIP veto is a catastrophic and ill-advised act of immorality and selfishness encouraged by people who are willing to twist any information to protect their health care profiteering without adding any value.
Saturday, October 13, 2007
The three best blog posts of the week from a humanities/literary perspective and my humble (I wish) opinion are:
I was struck this week by the eschatology of the third Great Transformation at Stayin' Alive. An interesting and brief essay. I'm usually the one causing others to crack the dictionary.
The ruminations on a personal placebo effect made me wonder how often my patients really do feel better when I do something. Not because I did anything different, just because it was me. I really need to be more available.
Dr. Hebert chimes in on race in America and the Jena six.
Have a great weekend. We'll be dining at Morimoto's in Philly on Saturday night.
Friday, October 12, 2007
We all know (or should know by now) that most policy is not based on a rational assessment of data. Science matters not a whit in the world of media pundits. All that matters is the trio of power, money and politics. In entertainment television news, the sound bite and five-second image makes the anecdote one of the most powerful policy tools available.
What? Nobody on the right anticipated that the Dems would parade a child affected by the SCHIP veto? Duh. The only possible response would be to attack the eligibility of the child and their family. "They're too rich." "They don't deserve help." Did anyone on the right realize their response would paint them as heartless goobers?
For the background, Graeme Frost is a 12-year old with a brain injury who was trotted by some pretty smart strategists looking to build opposition against the President's veto of the SCHIP reauthorization bill over Medicaid expansion. The Republicans attacked with a characteristic degree of opprobrium which was only unusual and inadvisable in its intensity. The commentary has been incredible (but Ann Coulter's miserably stupid misrepresentation of Christianity's beliefs is higher on the Technorati's top searches.)
Here is a sample of editorial and blog commentary:
Paul Krugman at the New York Times
Jean Marbella of The Baltimore Sun
The big pharma puppets at Drug Wonks
Ann Coulter wanna-be Michelle Malkin (talk about nauseating)
Multiple commentaries in the mainstream press collected by the Kaiser Foundation and on and on. They have been collecting opeds daily for weeks.
Jon Cohn (a conservative voice in support of SCHIP) in the New Republic, plus TNR's additional commentary on the blog war.
An exchange courtesy of The Cato.
Reproductive Health Reality Check
The whack jobs at Insure Blog analyzing the cost of insurance in Baltimore (laughable.)
The Health Care Blog
Megan McArdle, one of the most intelligent commentators on the subject, here, here and here.
Finally, Gary Schweitzer highlights the fact that this veto makes for great comedy.
I side with Megan, this entire blowup was predictable. Ronald Reagan was the father of the anecdote and the use of a personal story to drive policy. It is fair play. So what the heck did Republicans expect? The right's response has been an irresponsible, shallow, stupid knee-jerk which will galvanize the country and assure expanded coverage. This is the outcome of the SCHIP war.
Our problem now is how to pay for the coming health system and how to control costs. I am not sure how increasing consumerism in health care fits in with further insulating consumers from the costs of their health care. But finally, the debate will have to move to where it rightly belongs.
Wednesday, October 10, 2007
The sad state of palliative care in the US is a case in point. We don't even call it palliative care, we call it hospice, a term that needs re branding if ever I heard one. It conjures images of people left to die with no treatment save for pain medications.
It seems that there is a health disparity in the US defined for African-Americans' use of hospice. I call it the Tuskeegee syndrome.
African-American mistrust of the health care system goes far deeper than secret experiments undertaken on military pilots that did not stop until less than 35 years ago. The offer of comfort care to a black man from a white doctor is couched in layers of history and symbolism. Of course it's worse in a system that limits the kind of care that can be offered to a hospice patient. It does not look like palliation, it looks like giving up.
I had the opportunity to participate in hospice care for a brief time in Canada where it was considered active care for people who had no reasonable expectation of cure. We got a tumor lasered from a cancer victim's trachea, as a comfort measure. Suffocation and drowning in your own blood is not OK, even if you're silly with morphine.
I tried the same here once. The static was unbelievable. Maybe there are reasons that nearly one-half of Medicare's entire budget is spent on the last year of life? Perhaps if Americans dies with more grace and there was an ounce of trust between patients and hospice providers, the outcome would be different.
Medicaid patients tend to be low income, tend to have more wrong with them and tend not to take care of themselves very well. The RWJ funded the study because they were looking for ways to improve the performance of Medicaid in full realization that the outreach and provider effort necessary is much greater for Medicaid patients than others to get the same outcome.
This is the same trap Medicare P4P and non-payment for adverse events falls into: the outcome has a multi-source causation.
What a shame that we'll be arguing this garbage for the next week instead of focusing on the main issues of improving care, because the media is going to miss the point again.
Kudos to Alan Katz who compares Medicare and private insurance administrative costs. The conclusion is that Medicare is cheaper, but not so much, since the methodology of counting costs can lead to distortions.
So if we have established that private insurance costs more than Medicare to administer, doesn't that beg the question of what we are getting for our money? This value question deserves more attention and needs to be examined honestly and not as a rhetorical tool.
Tuesday, October 9, 2007
I got dumped on by an ER doc yesterday and I find it hard to believe. A man went to the emergency room with the complaint of several months of abdominal pain and a lump near the mid- line that he noticed only when lying down. I know it's not an impressive complaint and it has no business being in the emergency room. I know he was probably illegal (I noticed the hospital's tell-tale 111111111 SSN in the forms I was faxed) and he didn't speak English.
But I speak Spanish and got a straight history from a man who didn't know enough to lie about it. The ER was empty, so it wasn't busy enough to have the excuse needed to go into triage mode. The doc diagnosed a hernia, but the patient said he never dropped his pants for the necessary groin exam. In fact, when I go the ER note, it indicates he never found a lump, mass or hernia on the abdominal wall either. There was no indication of an inguinal exam.
So why did the ER physician send the patient to a surgeon? At least the surgeon had the sense to refer him to a county agency who in turn referred him to me. The surgeon later thanked me for at least taking the time to steer the patient in the right direction. I'll be seeing him in follow-up after a couple of weeks of anti-inflammatories for an abdominal muscle strain.
I did mention he was probably an illegal worker. That means manual work, remember? Muscle pains are still the most common complaint amongst manual laborers.
OK, so the ER doc was sloppy and probably had good reason for frustration. Then I hear about hospitalists complain about ER docs that don't complete a work-up before admission. Well, I thought the ER docs were supposed to ensure accurate disposition, not necessarily accurate diagnosis. So let's defend the ER docs at this point. The ER docs were hired to keep things moving and handle trauma and acute life-threatening medical emergencies. Hospitalists were hired to handle the flow between an admission decision and discharge.
Specialists complain about primary care docs not sending them sufficient information on consultations (mea culpa on occasion, but I usually keep it brief and accurate) and I never get any information back from the cardiologist, who went ahead and changed all my patients' meds and now she's confused.
Physician solidarity is a thing of the past and maybe, it's "good riddance."
There was a time that physicians' interests were considered an important component of the health care system. Now, we're just another cog in the wheel, and apparently, not a very important one at that. Maybe the reason is we don't respect each other and our skills any more. After all, no matter what the specialty we are all physicians. I can stand shoulder to shoulder with any physician in this country in talent, skill and acumen. But I have come to expect to be denigrated by my specialists for my choice of job, specialty and location.
If we could set aside the obvious differences in our personal and financial interests and focus on the patients and greater societal needs, maybe our opinion would count more than it does now. Maybe we would have credibility when we say we know what's wrong with the health care system.
Monday, October 8, 2007
Of course, too much of any good thing can be bad, as what might happen if you added a third oxygen to the molecule described above. Maybe the problem is not understanding that 'natural' things can be as toxic as arsenic or, more to the point, nutmeg.
Maybe it's just that we don't trust corporate entities that live or die by their financial performance. Why should the profit motive have an ethic sufficient to do 'the right thing'? it's certainly not the longevity of their 'good name'. Consider that General Electric is the only company in the Dow Jones Industrial Index at both of the last century turns. And of course, it is difficult to find data to convince people to override impressions formed by memory. Will you ever forget the images of Bhopal? Pharmaceutical companies have lied, I think. I can't remember where it was proven and where they settled, but was it Celebrex, Vioxx or...? Well, there's always DES. It was on the evening news, honest.
Some patients come in with long lists of medications; herbal medications that is. "Well, they're not really medication, " they say, puzzled that I even asked. I will not engage them in the argument, because they may not really care what I have to say.
But let's face it, many pharmaceuticals are derived from plants. The old remedy of foxglove, usually taken in a tea, has been very useful for "strengthening" the heart. It is very effective, since its major ingredient is digitalis. If you clean it up, get rid of all the plant bits, purify and compress it into a tablet with a very specific dose, you get digoxin.
How common was foxglove used in the past? It can be seen in the background of some Van Gogh paintings. But it has a downside, a very narrow dosage range between effectiveness and toxicity. Unlike nutmeg, which is only toxic in doses similar to the ones at which saccharine was fed to mice, foxglove causes as many heart problems as it solves. An interesting aside on the subject of Van Gogh, is that foxglove can cause psychological problems and some strange visual disturbances involving the intensity of the color yellow. The only way to take it safely is in a pill.
This brilliant commentary on herbal remedies has got me thinking, but a little chamomile and verbena is what I need for my cold right now. FDA is regulating everything else that might make me feel better.
Sunday, October 7, 2007
Then I read some fellow saying the Ken Thorpe is wrong about the problems with the health care system. I don't know if this fellow is right or wrong, I haven't bothered digging lest I discover another conservative ideologue, but he's using breast cancer screening as an example! This month of all months! And it's an irresponsible argument at that! Not to mention that Ken Thorpe didn't make any arguments in his article.
Leave to Health Despairs [sic] to claim that the major reason the US spends more on health care is because we are sicker. Confusing diagnosis (which is a function of being able to see a doctor multiplied by what the doctor can do time what the doctor gets paid for) for prevalence Ken Thorpe et al. claim that at least part of the underlying difference in prevalence is poorer health status. Really? He goes on to estimate that the prevalence of diagnosed cancer was 12.2 percent in the United States but only 5.4 percent in Europe in 2004. A huge difference. Even Thorpe has to write: "Are Americans really more likely to develop malignant tumors, or are they just screened more intensely than Europeans are? Comparisons of breast cancer screening rates and five-year cancer survival rates suggest the latter"Bad idea. It's a little more complicated and this guy doesn't seem to know Thorpe, since anyone who has met the man would be surprised if he ever made a claim that was not supported by the data. I would respectfully suggest the study is an example of how one tests a hypothesis. Once you design the study, you follow the data, wherever it may take you. Authors are permitted to suggest potential explanations for the data, but never state a 'claim', lest their objectivity and intellectual integrity be challenged.
The US is heavily doctored, but access is uneven. The wealthy take care of themselves wherever they may be. The middle class takes the brunt of profit-making, getting access, but not necessarily access to the best. How can you tell if someone is good anyway? How can you tell if you're being encouraged to have an investigation or a procedure just because it is billable?
So the hypothesis that more cancers are being detected earlier is certainly possible, given the data.
But the American health care system is not driven by cost-effectiveness as socialized countries are. There is no point doing a mammogram in a young woman because the test is not sufficiently discriminative until most women get into their 40's. It also detects a lot of abnormalities that are not cancer. PSA's are just not done in low-risk individuals for fear of extra cost for no benefit and sometimes even the potential of harm.
In the US, we have a consumerist society where the patient, now a client, makes the decision themselves. It's a little like picking out a purse at Coach, "I want two preventions and a diagnostic."
So in the middle of breast cancer awareness month, Robert Goldberg is suggesting that the European system rations health care and gives the example of breast cancer and mammography rates. However, in Europe mammography coverage is higher than it is in the US. So they don't need to ration by preventing people from having so-called unnecessary procedures. The procedures have, in fact, become moot. The are sufficient misconceptions about breast cancer, that women don't need someone muddying the waters.
The kicker, I guess, is that the US rations health care more than socialized economies. We ration by money so if the cost is prohibitive the test or procedure simply doesn't get done. Could this have an effect on Dr. Thorpe's data? Why don't we hear about it in the US? Well, the middle class can be vocal, especially when they can't get the handbag -- uh, I mean procedures they want, and still can't afford a better quality of advice... the one that tells them about the tests and procedures they don't need.
The US spends more money on health care because it misplaces its resources. Period.
Ladies, get your mammograms. For this test, there are funds available so that no woman in America should go without. I suspect, when all is said and done, it will be clear that European women who get free mammograms benefit from earlier detection. Thus these countries enjoy a remarkably low cancer rate. In the US, it is not a matter of cost, it is that women don't know they can get free mammograms through their local health departments. Citizenship doesn't matter. And it could save your life.
Saturday, October 6, 2007
I enjoy ranting about the use of rhetoric and logical fallacy. It somehow does not seem to be fair play, but on the other hand every public figure since Cicero has found ways to make their arguments more effective by shading the truth in a certain way. To me it's a different kind of lie, just not lying about facts, but rather how the facts are used. The idealist in me doesn't want to fight lies with more lies.
Well, do not lament Truth. She is hardier than any of us and certainly doesn't need my help to survive. I need to find a way to get over that.
There was another instance of misplacing my funny-bone this past week. I think it matters because, while Peter Rost lost my interest with his attack on physician salaries, there are so many opportunities for physicians to become hard, cynical and uncaring. If Peter and his buddies do not care, there will not be a physician work force worth a damn in a couple of more decades. We (all of us) need to take care of our physicians. Yes, we need to nurture them because they are exposed to some of the worst situations that humankind can devise.
I must confess, one of several reasons that I retreat from full-time practice is that I have trouble dealing with the emotional impact of having so many people I cannot help. On the other hand, my response to Half-MD's developing cynicism may have been an over-reaction tainted by some bad experiences of my own. Please let me know, I always seek feeedback, especially when I could have screwed up.
While I work to control my temper, I also think I need to keep things fresh and quit ranting about US health policy. There's plenty more inanities out there than just the US health care system. I am discovering more blogs I love, but haven't updated my blogroll. I still haven't picked an analytic tool for the blog, so you may see three widgets in different places. I have to fix the alignment at the bottom of the page and clean things up a bit.
To be fair, my laptop crashed on my trip to the desert a month ago and I just got a new one this week. I have some catching up to do re-establishing a number of routines.
Any advice is always welcome.
Again, I find that my true pleasure seems to be the few exceptional essays I have read this past week. I will call this health care literature, since a well-written essay is next to the short story and novel as the most difficult writing challenge.
This week it was Vitum Medicinus' post on palliative care (that's hospice in the US), and the Medblog Addict's self-described 'Corn,' which is the opening of a heart-wrenching salute to a friend. Sid Schwab does it again, moving me with a couple of postings this week.
It occurs to me that there is no carnival, roundup, or top post list for literary level health care blogging. Given the number of people who are interested in medical literature, art and the humanities, this is surprising. Kevin, MD's Power Blog 8 seems to focus on the most thought-provoking, and well-writen blog posts, but does not focus on literary form. I may make this a weekly feature...any thoughts?
Beats bitching about bad blogging.
Friday, October 5, 2007
My thoughts on cultural differences engendered by physicians' training are relevant but this post takes it further.
I know... I know... I'm name calling again. Fox-news-eating anti-intellectual scum that they are...
But check out the following interchanges:
TSC Daily: propaganda, let me count the ways. Anyone who has ever learned something about rhetoric and logical fallacies can use this site as a guidebook of how to win an argument at any cost to the truth. (I'm not a philosopher, but is this a symptom of post-structuralism?)
Then there's Emily DeVoto, who bothered to review the data on the lack of health coverage. Her posts are generally well thought-out and ask more questions than trying to ram so-called answers down the reader's throat.
At the other end of the spectrum, there is discussion and an interchange of ideas. A Healthy Blog is run by Heath Care For All, with an overtly liberal/progressive bias. Naturally, someone suggested using tax policy to incentivize healthy behaviors. This is an idea with a long pedigree, several examples of having worked in the past and arguments to commend as well as grounds to criticze. The discussion did not take long to degenerate as a couple of bizarre responses were appropraitely cut short.
I am being unnecessarily provocative, but please people... wake up! There is a problem here. Educated people are taught to be tolerant to contradictory ideas, but there is a crop of individuals who call themselves conservative but are nothing more than anti-intellectual radicals passing their ideas off as valid. They have gained sufficient currency to be seen on network news berating 'liberal' media (a paper tiger if I ever heard one).
There is much to discuss in art as in life and disgareement is at the core. The rules of civilized discourse have been rent. There are serious conservatives whose opinions need to be heard, consdered and discussed. I suspect Dr. Thorpe would describe himself as a conservative if pressed (it was his research that was the subject of A Healthy Blog's post.) Alan Greenspan is a conservative with some intelligent points to make. George Soros strikes me as someone with a very conservative capital-oriented orientation but he is also progressive and a significant intellect. As he stands against these Neanderthals, he has been viciuosly attacked by both media and instruments of government in the US.
What some shrewd forces, passing themselves off as conservatives, accomplish is give currency to outrageous ideas and toxic policies . These ideas, in turn, influence politics to the extent that policy is made based on junk data with faulty logic by bad intellects.
Sometimes we get the government we deserve.
Thursday, October 4, 2007
So why not cover spas (which, if I am not mistaken is a partially- covered benefit of some European health plans)?
Here is a well-known writer describing the limits of self-improvement while exploring a spa. At least it's not a Medicaid benefit.
Barbara Starfield has show a correlation between a county's health status and how friendly it is to primary care.
Saudi Arabia appears to have taken note. The Kingdom is seeking 13,000 family physicians to staff community health centers in response to unnecessary costs imposed by the burden of chronic disease.
And in the US? Primary Care has seen better days...
Specialty care may not add much to macro level health measures, but primary care has no credibility without the back-up. What use is primary care without access to secondary and tertiary levels of care?
We talk about health reform, but to what end? Think carefully, because the goal one wishes to accomplish has consequences for the actions one would take.
To improve health status, support primary care.
To control costs, support primary care.
To deal with the emotional and economic consequences of becoming ill, pick HillaryCare II. Better than nothing, since the only way to get inexpensive basic policies that work is to... wait for it... support primary care.
To the right, I look like Lenin. To the left, I appear to be somewhere to the right of Attila the Hun. If I don't agree with either position, derision seems appropriate.
After all, what is a non-conformist who does not meet the expectations of a group of non-conformists. Many intelligent persons would like to characterize themselves as independent thinkers with insights that few others have.
Perhaps it is time to establish a manifesto, one for an affirmative and radical centrism. If progressive thinking, generally seen as coming from the left, is concerned with the ideals of human existence, it is a good place to start. If conservatism protects the status quo, it serves to remind us that not everything that works poorly is broken.
I would advocate that government indeed has a responsibility to better the life of its citizens (a liberal idea), but that government must act parsimoniously, accountably and with a view to empowering individuals to take control their destiny as much as is possible (a conservative idea).
As the country slowly returns to the center, health care is an appropriate area in which to express an enlightened conservatism and a kind of radical attachment to logic and data devoid of ideology as the essential ingredient of policy.
Health Wonk Review is full of very thoughtful analyses.