David Longstreet had this to say in response to Andre Blackman's post last week on the the increasing importance of technology in public health. ("Why Technology is No Longer Optional in Public Health."

"the biggest change in software technology is the growing trend of specialization along industry disciplines. The healthcare field is too complex for "generalist" software developers.  Those software organizations that specialize in healthcare have productivity and quality rates orders of magnitude higher than generalist firms.

This should not surprise anyone in the healthcare discipline because healthcare has understood the value of specialization for some time now.  Unfortunately there are still software firms whose employees work for a bank one week and a hospital the next week…."

Christopher George wrote in reply to Bob Wachter's piece on the implications of comparative effectiveness research.  ("Are We Mature Enough to Make Use of Comparative Effectiveness Research?")

"Because the only case which you discuss is one in which supposedly greedy doctors perform ineffective surgery for profit, one might be left with the impression that the principal problem in healthcare is restraining rapacious doctors.

It is well known in certain segments of the medical community that back surgery, and cardiac angioplasty are largely ineffective. It is also well known that regulators with government sponsorship have a limited grasp of statistics and science, and an uncanny tendency to target effective procedures as often as stupid ones. Don't be surprised if you don't like the result once a soviet style Supreme Extra-ordinary Medical Committee makes enforcable decisions about what heathcare is on your treatment menu.

Remember  an early target of those who would use government to eliminate medical progress: The CT scan. The assault on the Cat scanner was nearly successful. When you torture the data enough, a CT scanner can seem like a silly thing to use. Why not practice like they did at the dawn of time?"

John Lynn wrote in to address John Haughton MD's prediction that the majority of doctors will pay less than $10K a year for EHR service

 "There already are a number of EHR (sic) in the $10k a year range.  The question is how many of the CCHIT certified EHR are in that range.  Not very many.  If CCHIT becomes the certification criteria that HHS uses, then your prediction will not come to fruition.

Also, don't be at all surprised if many doctors ignore the stimulus altogether.  Those that do pay attention will hear about the missing bonus payments from ePrescribing due to some government requirement and shy away from this stimulus as well.

JD had this response to Maggie Mahar's post arguing that tax increases will be needed to pay for the sweeping changes to the healthcare system planned by the Obama administration …

I'm all for realism when it comes to what we can accomplish in the next few years, but to say that we need to pay higher taxes, without saying that this is temporary and only until we are able to reform our system from being the most wasteful in the world, seems to miss the mark and not set us up well for subsequent rounds of reforms that must eventually come. Also, since we are in a deep recession, this is the one time I disagree that we need to pay-as-you-go. I mean, are we not Keynesians here? New taxes need to be few and far between right now, and focused very narrowly so that they don't harm the economy. Better to give more people coverage in 2009 and 2010, deficit spending to do it, then try to bring the hammer down on costs after that, rather than raise taxes.

Randall Oates MD liked what Val Jones MD had to say in this morning's post on improving physician performance. ("How to Win Docs and Influence Patients.")

"Amen! Building on the approaches that show evidence of success will meet far more success than theoretical, centralized planning attempting to force change. In my role promoting physician adoption of EMR’s, I have opportunities to relate to dozens of physicians every week. Most physicians are very interested in better use of information technologies, and most are already demoralized by the controlling entities attempting to force square pegs into round holes. "

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9 replies »

  1. jd,
    Money was invented to determine who could have what. Statutes were invented to steal under the cover of government.

  2. Ms. Mayar,
    Since when is income the same as wealth? An income tax is not a wealth tax. The 1.8% over 250 are Americans, too, not indentured servents, or worse. The 95% may be getting an income tax cut, but there are many other ways of taxation, all of which will go up. So they will get one tax cut and fifty taxes increased.

  3. Matthew-
    j.d. wrote “we will be paying higher taxes.”
    As I explained in my response (and as I am sure you understand ) only very wealthy people (in the top 1.8 percent in terms of income will be paying higher taxes.
    And they will be paying higher taxes ONLY ON THE DOLLARS THEY EARN AFTER THE FIRST $250,000, (This is their “marginal tax rate.”)
    In other words, if you earn $290,000, the extra taxes wouldn’t be much.
    Meanwhile 95 pecent of Americans will be getting tax cuts under Obama’s plan.
    These facts should be included in any discussion of Obama’s tax increases.

  4. Personally, I think almost all back surgery,(I must see a lot more post op patients than you do, because these operations do WAY more aggregate harm than good.) interventional cardiology, (not cholesterol management), most cancer treatment, nearly all non-emergency ER care is a complete waste of money.
    CT scans are way overused.
    We are going to have a rash of breast and thyroid cancers in worried well with occasional shortness of breath in a few years.
    But for head trauma they are essential. Still. This simple fact was lost on the administrative doctors of a generation ago.
    Also remember Mammography, something that actually saves lives by the tens of thousands was on the Hilarycare Chopping Block, to save money.
    Most medical care does not extend life. Don’t drink, don’t smoke, don’t get fat, and your life will far exceed the average without any medical care.
    My point is simply the medical political process gets almost everything WRONG. Giving them more power is going to make things worse. In the brave new world, back surgery is saved by its political friends, and bedictin is lost to its political enemies.
    How do we make these decisions better?

  5. MD as HELL, in the first post you point to CT scans as something often done not for the patient, but for the physician’s protection against lawsuits. In the second post you say that when an insurer denies something, it refuses to accept the consequences of abandoning the patient.
    If we go back to the CT scan example you gave, the insurer is not abandoning the patient at all. It is refusing to pay extra to subsidize your malpractice insurance (or pad your pocketbook). Not exactly the same thing. This happens all the time, as you must know.
    Of course, it also happens all the time that insurers deny something for more purely bureaucratic reasons (name spelled wrong, pre-auth not sought, etc., etc.) I agree with you in those cases the insurer is being an ass, as would just about anyone.
    There is a third class of cases where insurers “abandon” the patient that is tragic but not about being an ass or trying to (however ineptly) pay only for medically necessary services. When someone has a policy that has X level of coverage, the premium reflects that level of coverage. That becomes the reality the insurer has to live with. They cannot afford to give the person more coverage than X, because then they go broke. Despite what every doctor seems to believe, health insurance is a low margin business (3-5% net income). They can’t just ignore what the contract says the person is covered for, because they won’t be around next year if they do.
    Now, of course, that is the beginning of an argument both for a lower cost universal health care scheme and for getting real about the rationing of care that happens inevitably, whether you ration by cost or by statute. But those are different topics.

  6. bev M.D.
    The inept bureaucrat will be just like any other payor…”we only said WE will not pay for it…not that the doctor should not have ordered it.” They will insist the practice of medicine is left to the MD without accepting the consequences of abandoning the patient, leaving him with no coverage for a test or treatment.
    I will not be able to retire any time soon, but I don’t have to be as productive as I am, if I am only to work harder for less.

  7. MD as HELL (BTW that’s a good moniker; hope you can retire like I did):
    Yep, you are dead right. So maybe an inept bureaucrat might work FOR you this time: “sorry, ma’am, the govmint won’t allow a CT just because Johnny hit his head.”

  8. CT scans are more for risk management than for diagnosis. When a kid hits his head or the geriatric patient on coumadin falls and hits the head, but has a normal exam, CT is often obtained, but only for risk management. When silver-tongued plaintiff attorneys can make you look negligent in front of the jury without a CT, you will get the CT. Even my favorite surgeon would not operate on my wife with a classic appendicitis without a CT, yet we both started in the age of medicine before CT.
    CT is a test patients request by name. They aren’t requesting a CBC or a Comprehensive Metabolic Profile.

  9. Matthew;
    Because Christopher George’s comment seemed directed at my previous comment that back surgery and stents are ineffective in the wrong group of patients (he generalized where I did not), I feel compelled to reply now that you have publicized his comment. Although I did not bother to reply to him at the time, there is clear evidence that CT scans themselves are now vastly overused and, not only that, are producing significant excess radiation exposure to patients. (This was published in the New England Journal, but I am too lazy to find the reference.) So maybe the inept government
    bureaucrats he cites were at least partially on the right track, eh? Not that I favor governmental control of medical practice, far from it. But the issues are not as clear cut as many would like to paint them.

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