Category: Medical Practice

PHYSICIANS/POLICY: Where’s the outrage? by Eric Novack

Eric Novack is a bitter, twisted physician (just kidding Eric!)in fact he’s outraged! Why? Apparently he wants to be paid on time and doesn’t want to work for free! Read on:

Where is the outrage? Where are the NY Times editorials? The ACLU? In fact, Novack_sm_1anyone?

On September 22nd, 2006, the government will officially stop sending Medicare payments to physicians. The government has stated categorically that CMS will not be responsible for late charges, interest, or other penalties that could accrue during the payment stoppage. How long will the refusal to pay last? To quote CMS, it will be ‘brief’. It will just last 9 days. Payments will resume on October 2nd, 2006. Read the CMS summary yourself

Why? How could this be? I thought Medicare is the ‘solution’ to our healthcare woes, it just needs some tinkering with more technology and ‘performance incentives’?

The reality is that the much esteemed Medicare system that many THCB aficionados want for everyone is flat broke already. Not in the next 50 years, not for the next generation. Now. In the same way that we think that we will just backdate that check to our landlord, in the same way we just miss one mortgage or car payment by a week or so to wait for the paycheck to register in our account, the government is passing the bill for this year’s Medicare program onto the next year (the beauty of the fiscal year…). Math time: 9/365=2.5% (or 0.0246 for the disbelievers among you) Total Medicare Part B gross estimate (very rough) of $150 billion x 2.5%=$3.75 Billion.

Quite a ‘late check’. Except that the government refuses to pay a late fee. The government says too bad. Perhaps next year the ‘no pay’ period will last 2 weeks? 4 weeks? Perhaps the government will decide to not pay to ‘catch up’ on late payments? It is not a question of if, rather a question of when. Quoting Benjamin Rush at the Constitutional Convention of 1787: “Unless we put medical freedom into the constitution the time will come when medicine will organize into an undercover dictatorship and force people who wish doctors and treatment of their own choice to submit to only what the dictating outfit offers.”

This is a time for courage. The courage of US physicians to remove themselves from the Medicare system as it stands and demand a system that respects the rights of not just the patients of America, but also the providers.

HEALTH PLANS/PHYSICIANS/TECH:Health care, the way it should be (or How to stop worrying and learn to love the bomb), by Pat Salber

Pat Salber writes The Doctor Weighs In. She is a doc, an ex-med director at California blue shield, and a Kaiser Permanente member. And she loves them. This is why, and it’s quite an advertorial for Kaiser and an indictment of how everyone else does it. So if this becomes the standard, and people find out about it (and with $80m of advertising budget a year behind it, they will find out) can the rest of the US system compete?

Health care, the way it should be or  (How to stop worrying and learn to love the bomb)


I have to tell you again about what great health care I get from Kaiser Permanente Northern Cal. Drhealth (Yeah, I know, they screwed up on the transplant service).  But, they are doing a lot of the things we, the wonks, have been hollering about for years.  Read this.

Sunday night I noticed new “floaters” in the right visual field of my right eye.  They were different from the run of the mill floaters – those little dark circles — most of us have.  These were like long lines and they only moved on the right side of the visual field.  The next day, I started having sparkling lights, again in the right visual field.  Now, even an emergency physician knows this could indicate a retinal detachment (serious indeed).  So mid-afternoon, when I had convinced myself it would be stupid to miss my own diagnosis, I called KP.  The woman on the phone in the opthalmology department clearly had been trained.  When I talked about the sparkles, she put me on hold and got a nurse. 

The nurse tried her best to get me in the same day.  She had an appointment available, but being rush hour, there was no way I could make it. She carefully went over the symptoms of retinal detachment and compared them to what I was experiencing.  Together we decided it was OK to wait until the next am for an appointment.  She carefully explained that if certain symptoms occurred (e.g., a sensation of a curtain coming down over the eye), that I needed to go to the emergency department right away as that could indicate a retinal detachment.

The next day (today) I showed up at the opthalmology department.  The receipt I was given for my $15 co-pay listed the dates I had had all of my age/gender specific  preventive services and the dates the next ones were due.

There was no wait to see the doctor.  I was put in an eye exam room and saw a nurse right away.  She explained everything she was going to do.  She anesthetized my corneas,  she tested my vision (with glasses and with pinholes), she used the slit lamp to look at the corneal surface, and then she put in drops to dilate my eyes.

After about 15 minutes (waiting for the eyes to dilate), Dr. Prusiner, chief of the department came in to see me (he is the brother of Stan Prusiner, the Nobel Prize winner who discovered prions).  He did a very thorough exam of both retinas using a variety of techniques.  He explained that I had a vitreous detachment (annoying, but otherwise, no big deal).  He showed me a color picture of an eye with a vitreous detachment.  He answered all of my questions.  He did  not seem rushed (because the nurse had done a lot of the early work for him).

We were finished, he gave me a  4 x 6 piece of paper with his name, his photo and the URL of his home page.  Here’s the link  so you can see how nice it is.  This is, I think, the new KP Connect.  It also showed all of the stuff (by major categories) that he had on his home page.  He wrote down the diagnosis “vitreous detachment” on the paper and drew an arrow from it to name of the link where I would find the information he had chosen for his patients to read about this condition. He urged me to read it.  I went on the site, found the condition, and, lo and behold, everything he told me was what was on the site.

He then told me, in detail, what symptoms would require me to call or go to the ER right away.  But he assured me that the symptoms represented complications highly unlikely to occur.

By the way, he said as I was leaving.  Be sure to make an appointment with the optometrist.  I think we can improve the correction of your left eye.

I challenge you to find one single thing you would want that I didn’t get.  This is the way health care should be.

QUALIY/PHYSICIANS: P4P in the United Kingdom

The biggest P4P scheme in the world is going on in the UK, one that I first wrote about in early 2004. (For more on the  wider ramifications of reform in the UK ,see yet another article in this weeks NEJM

Note that all the GPs there have computers, so they can easily report their process behaviors. Note also that the introduction of the system as done as a way of giving extra cash to GPs, but extra cash for improving quality of primary care process. So the first year’s results are in, and the GPs have done much better than was predicted and better than most American groups studied other than the VA. I think this is so important in the light of where Medcare is going that I’m including the entire discussion section from the NEJM article from the Univ of Manchester group that studied it. It’s called “Pay-for-Performance Programs in Family Practices in the United Kingdom”, and its below the jump, as an exceprt from an article by Arnold Epstein commenting on its implications for the US


Continue reading…

TECH/QUALITY/PHYSICIANS: Healthcare and The Long Tail – Searching for help when you’re on the wrong-end of the curve by Jim Walker

Two things have got my attention recently. The first is the concept of the long tail in medicine, which I’ve thought about alot since my fiancee got an odd condition (shortness of breath) that didn’t match any of the symptoms the text books said were the symptoms of the usual shortness of breath. She endured several doctors diagnoses of diseases that went from the wrong to the ridiculous (panic attacks that lasted for weeks?). After much, much digging around on the web she found a patient testimonial from someone who had long term shortness of breath and related it to caffeine. Yup, drinking coffee was causing the problem. But because it was a rare symptom of what’s not normally a medical problem she had to go through the annoyance (and worry) of being wrongly diagnosed and put on drugs she didn’t need, and now she can’t drink coffee or eat chocolate—her life  must barely be worth living!

The second is a plethora of people writing to me telling me about XYZ product that is the greatest since sliced bread and would I please praise it on THCB. One such person is Jim Walker from new physician social networking site MyMedwork. Usually when I request that said person writes a piece putting their service in context I get self-serving marketing jargon, and when I request that they instead really write a general interest piece I never hear from them again. In contrast Jim wrote an excellent explanation of the Long Tail in health care. Here it is:

Healthcare and The Long Tail


My neighbor brought her son to the doctor this summer for a rash that
wouldn’t go away. “The doctor had never seen anything like it,” she
explained.  “In fact, he brought in the other doctors to take a look at
it, and none of them had ever seen it either.”  Now I don’t know about
you, but listening to her reminded me of my worst medical nightmare of
things I don’t ever want to hear from my doctor:  “Excuse me, do you
mind if I bring in some of the residents? We’ve never seen a case like
yours before.”

In a recent THCB post,
author Maggie Mahar writes that “Ambiguity haunts medical care”. She
goes on to quote Dr. Atul Gawand – “Uncertainty is the core predicament
of medicine . . . the thing that makes being a patient so wrenching,
being a doctor so difficult and being part of a society that pays the
bills so wrenching."


It’s important to note that for a great
many cases, ambiguity is not really an issue.  This is because the
distribution of medical ailments follows a curve very similar to Chris
Anderson’s “Long Tail”,
with a great many common “blockbuster” ailments stacked up high on the
left-hand side of the curve. For those not familiar with the Long Tail,
Anderson describes how Amazon, Netflix, and other online retailers sell
lots of the usual blockbusters, but actually derive more total volume
from 100s of thousands of niche products.  In healthcare, it is the
left side of this distribution curve which inspires (for better or
worse) Wal-Mart, Target, and others to offer “Doc In A Box” services –
Allergies, Bladder Infections, Bronchitis, Ear Infections, Pink Eye,
Sinus Infections, and a full battery of vaccines – all served up for a
fixed price while you wait.


On the right hand end of the
curve though, the NIH Office of Rare Disease classifies over 6,000
conditions, each afflicting fewer than 200,000 Americans.  Along this
part of the curve, things do indeed get very ambiguous in a hurry –
both for patients and physicians. Specialization is a response to this
range of ailments (“nichefication” in Anderson’s terms), and brings
physicians repeated cases of a particular nature – giving them the
confidence that they can routinely diagnose and treat a high percentage
of these patients. However, even within a particular specialty area,
cases will naturally follow a distribution curve from typical to
atypical. Unto themselves – atypical cases are just that – one of a
kind aberrations that force physicians to go outside their typical
“comfort zone” of diagnosis and treatment.  For each individual
physician, these atypical cases feel like the exception rather than the
rule. What the Long Tail suggests though, is that taken in their
entirety, these rare cases actually compromise a large percentage of
all medical cases. In fact, over 25 million Americans suffer from a
“rare” condition.


This is problematic, because in general,
physicians – and the healthcare system as a whole – are not well
prepared for dealing with the many and inevitable rare cases. In fact, statistics show
that the median time to diagnosis of a rare condition is six months,
and the average is almost three years! When faced with an atypical
case, most physicians will begin to consult the literature, and/or
confer with their colleagues. Ironically, it is at this moment that the
Long Tail shows up again in a quite surprising and often detrimental
fashion. This is because recent studies in social and information
analysis reveal that our network of professional contacts and
information sources follows the same type of distribution curve. In
other words – we all generally tend to connect with the same 15 or 20
trusted colleagues on a regular basis, and we all gather our
information from a limited stream of trusted sources. Beyond this
trusted core lies an entire world of other people and sources we rarely
connect with, if at all – our own social and information “long tail”.
Generally, using a network of trusted sources (while tuning out most
everything else) is actually very efficient at handling a majority of
our day to day needs. For the atypical situation though, just when we
really need to break out of our habitual way of doing things – our
trusted sources generally don’t deliver. They’ve all been drinking from
the same information punch bowl.


So, we have to head out to
the right-hand side of the curve – and begin finding and evaluating
people and sources we don’t really know. For a student or researcher,
this type of research can become a time consuming, challenging, but
often rewarding journey. But, for a patient and physician confronted
with a puzzling and life threatening illness, the stakes are much
higher and time is at a premium. In today’s system, the physician often
must address this dilemma by referring the patient to some other
specialist – with the hope that maybe they will have the knowledge or
connections to form a proper diagnosis and treatment protocol in a
timely manner. The patient of course, must continue to move from
specialist to specialist, their rare case still in hand.


surprisingly, the Internet has proved both boon and bane in this
situation. Patients and their families are using the Web to dig into
the latest medical research. However, matching a worried patient or
family member against 1,706,532 Google results is usually a
prescription for both confusion and high blood pressure.


a more encouraging note, patients stuck along the right-side of the
curve with a “niche disease” are using the extraordinary reach of the
Web to discover that they are not so atypical after all. It’s probably
no surprise to THCB readers that patients are banding together around
wikis, chat rooms, blogs and social networks to offer each other
information, empathy, and inspiration. (This is not so different in
network theory terms from when fans of a niche band find each other on
MySpace). Some of these disease state patient networks are sponsored by  pharma marketing, while others are grass-roots efforts, usually led by  a parent or family member related to one of the patients.


are also turning online in large numbers. Manhattan Research reports
that more than 600,000 physicians are using search engines to find
medical information. Are they searching about how to treat their
day-to-day typical cases? Very unlikely. Chances are, they are
researching an atypical case. However, if two physicians search – for
example, on “phylloides tumors” at Google they each receive the same
list – but have no easy context by which to evaluate the 13,600 +
search results! 


Social network software may be one way to
help physicians overcome this “search result overload”, allowing them
to move faster and more confidently outside their circle of trusted
sources and down the long tail, especially when faced with a “rare”
condition (which as we’ve noted – is not such a rare occurrence in the
aggregate). For example, within MyMedwork
, search priorities start with the individual physician’s network of
trusted colleagues and work outward from there. In other words – each
physician gets a totally unique list of search results based on who in
their own extended network is likely to possess useful information.
Because the medical community is so small, it turns out that physicians
are usually quite closely linked to any given article or study, they
are just not aware of the connection. By viewing the social network
connection within their search results – they are then in a position to
more accurately judge the quality of the information – either by
checking with the in-between link (i.e. “Hi Dr. Jones, I notice you’re
connected to Dr. Watson – what do you think of his study on phylloides
tumors?”) – or by contacting the physician directly (i.e. “Hi Dr.
Watson, I see you went to medical school with my colleague Dr. Jones,
do you mind if I ask you a few questions about your study?).


implications of The Long Tail and social network analysis for
healthcare are just beginning to be explored and understood. It is
already clear though, that as the entire healthcare field continues to
undergo dramatic change, and “atypical” rare disease states become ever
more typical, ambiguity and uncertainty will continue to impact medical
decision making. In this environment, the need to develop richer and
more varied sources of information, and the value of far-reaching,
online social trust networks will become increasingly apparent for
patients and healthcare practitioners alike.


Or we’ve got mail. Or we’ve all got mail. Or something … 

After much late night heroism by THCB’s trusty (and highly
sensitive) tech staff, the THCB email list is up and running. If you’d
like to get a quick email in your inbox with a rundown of new posts –
with news flashes for important stories – you can sign up here.

If you subscribed to the list in its earlier incarnation, there’s no need to do so again.

QUALITY/PHYSICIANS: Just what we need now, another grandstanding politician on end of life issues

I’ve been having a backchat email with the people from the Tenet Shareholders Committee. They are enjoying the legal  attack on the Louisiana physician who is supposed to have performed a mercy killing or provided ample pain medication at Tenet’s Memorial Hospital a little too much for my taste. Admittedly they are so opposed to Tenet that this one is too easy for them. But I doubt this one has anything to do with Tenet, which frankly didn’t do much to help its patients (HCA was a little more honorable).

But where the hell was the Louisiana or New Orleans AG (or for that matter any other level of government) when desperate physicians, nurses and patients needed help? Absolutely effing nowhere. A humane person wouldn’t leave a dog to slowly die or drown in the 105 degree heat, let alone another human. And it seems to me that in absolutely desperate circumstances, Dr Anna Pou did what she felt was best for those patients.Yet six months later a grandstanding DA gets his jollies off by sending physicians and nurses on trial for homicide.

This is total bullshit. A series of studies in the 1990s showed that physicians routinely ignored DNR orders. I don’t recall any of them being prosecuted, but they probably caused more harm and inflicted way more distress on patients than Dr. Pou would have done under any normal circumstances…..and let us not forget—those were anything but normal circumstances. If I was a patient there suffering with no water, no power,and no hope other than suffering a long agonizing death—I’d have been very grateful for the relief Dr. Pou’s care would have given me in my final hours.

And now we’re going to send her to jail?!



I recently met Michael Howe who is CEO of MinuteClinic, and he had the good graces to call me back and talk on the day that they sold out to CVS. Very classy as it would have been easy to blow me off.

So the rumor quoted here is that CVS paid $170m for the company—certainly an endorsement that they at least think that retail NP clinics are real. But if you want to really know more, look at this new report on retail clinics from the California Health Care Foundation written by Mary Kaye Scott. Very nice summary indeed.


This is more of a public service announcement, but Med Solutions offers a service which can put you in touch with all the patient assistance programs from big Pharma. It looks to be well worth checking out if you need drugs and can’t afford them.

QUALITY/PHYSICIANS: Klein on malpractice

Ezra Klein has written a pretty good state of play about Medical Malpractice over at Slate. As you know I’m all for putting the solution for malpractice within the context of an overall medical error/practice guideline/EBM policy. Of course, politically the AMA and the docs are being used by the “tort reform” lobby who don’t give a rat’s arse about doctors or patients but are using them as sympathetic front men in their campaign to make corporate malfeasance unpunishable by any branch of government. So politically I wish the Democrats would sell out the trial lawyers on this one and work towards a wider solution (as Ezra suggests they might do). Not very likely of course, but slightly more plausible than the AMA cutting a deal, or the Republicans doing the right thing.

POLICY/PHYSICIANS: Too many doctors

Dartmouth worthy David Goodman has an op-ed in the NY Times called Too Many Doctors in the House. It makes the arguments that you all know well, but it does contain this lovely zinger.

The association of medical colleges has argued that increasing the doctor supply overall can remedy regional shortages. But in the past 20 years, as the number of doctors per capita grew by more than 50 percent, according to our measurements, most of the new ones settled in areas where the supply was already above average — places like Florida or New York — rather than in regions that lack doctors, like the rural South. Medical training is an expensive business, and it makes little sense to waste additional public dollars to perpetuate doctors’ preference to live in affluent places. (my emph added)

PHARMA/PHYSICIANS: Yet more on Rx data sales

The NEJM has a perspective about the sale of Rx data of physicians prescribing patterns, which caused a lot of fuss on THCB a while back. In my view this is problem about number 728 on the docket of what’s wrong in American health care, and those physicians complaining about it should look to solve the first several hundred before they set their sites on changing the law, or just kick the drug reps out of their offices. There’s nothing particularly good about the current situation but it’s just not that big a problem and banning the sale of data won’t change it too much. the perspective from Robert Steinbrook largely agrees.

Prohibiting the release of prescribing data to sales representatives will not put an end to another practice to which some physicians object: the use of such data by managed care or pharmacy benefit managers. These entities have sources of information that are independent of the AMA Masterfile. It also will not stop visits from sales agents, which doctors have always had the right to refuse, nor will it curtail the marketing of drugs. According to the AMA, the potential effects of restricted release may include a reduction in the number of “offers physicians currently receive from the pharmaceutical industry, such as drug samples, CME programs and speaking engagements.”


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