Category: Physicians

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.”

PHYSICIANS/POLICY: Brian Klepper on the end of life as we know it, or something like that

Brian Klepper was recently up at Medscape bemoaning the lack of physician leadership in righting the troubled ship of our health care system, and challenging physicians to do better.

He got lots of feedback, not all of it as negative as you’d think, and he had his own response. All well worth reading.

On the other hand, HSC says that in real terms we’re paying physicians substantially less than in 1995. I suspect that most of that pay "cut" was in the 1990s, and things seem to be picking up again, but — as one reader asked me — there is not that much good data on physician incomes, and in real terms they did very well between 1960 and 1990.

PHYSICIANS/TECH/POLICY/POLITICS: Hard to generate savings when you spend more, eh?

The real medical story of the day is of course Michael Owen’s torn ACL, which leaves the idiot Swede’s decision to take only one fully fit striker plus a kid he won’t play to Germany as dumb as they come. But you lot don’t care about that. Instead let me tell you about my conversation with a consulting firm looking into home monitoring. The people interviewing me, once they’d got past my somewhat cynical notions about how technologies get reimbursed by Medicare and whether private insurers actually give a rats arse about saving money, kept harping on about reimbursement and how to get home monitoring reimbursed.

I made a point that will be all too familiar to THCB readers that if (and it’s not a tiny “if”) remote monitoring of the chronically ill, and all the DM processes that go along with it, is to be done routinely, then someone somewhere will have to give up some of their income to pay for it. In other words, if catching bad things happening to patients before they crash is the end result of home monitoring, there’ll be less money spent on the ones who crash. The optimists among us believe that the amount of that money not spent will exceed the amount spent on the home monitoring and DM, but that’s a subsidiary point. Instead the key issue is that under our current diversified system the people not getting the money for the patients (e.g. doctors and hospitals) who no longer crash are going to be different from the people who get the money for the monitoring (e.g. tech companies and DM service providers).

So if DM programs based around tech use, like the Medicare Health Support pilots or BeWell Mobile’s asthma DM program, are to be successful then they’ll either need additional funding from payors, or redirected funding from payors. When you have a global budget, like the VA, then it may well make sense to bring in this type of program, which is why Health Hero Network is having success with the VA, but struggled to get wide adoption outside it before. But, and you all know this, the VA, Kaiser et al are exceptions.

While leads me to the second part of the equation; how willing is the rest of the system (those doctors and hospitals) to accept less money for any reason—let alone subsidizing the adoption of new technology that will benefit someone else? Well you know the answer to that one, and yesterday came more proof, as apparently the AMA has beaten the Republicans to a bloody pulp and will not have to deal with the draconian fee cuts that were coming their way.

So I remain a skeptic that we’re going to spend more to spend less; I just think that we’re going to (slowly) just spend more.

PHYSICIANS/POLICY: Physician Shortage Looms–hold onto your wallet

Quoting a bunch of head hunters and a rural doc who can’t find anyone willing to move to Ukiah, the Los Angeles Times says this:

A looming doctor shortage threatens to create a national healthcare crisis by further limiting access to physicians, jeopardizing quality and accelerating cost increases.

And so apparently we must build more medical schools and train more doctors, even though the doubling of the number trained in the 1970s hasn’t fully worked its way through the system and won’t for another ten years.

Momentum for change is building. This month, the executive council of the Assn. of American Medical Colleges will consider calling for a 30% boost in enrollment, double the increase it called for last year.

Meanwhile the Dartmouth guys (who maintain their starring role in THCB) say something oh so slightly different:

AMC inputs were highly correlated with the number of physician FTEs per Medicare beneficiary in AMC regions. Given the apparent inefficiency of current physician practices, the supply pipeline is sufficient to meet future needs through 2020, with adoption of the workforce deployment patterns now seen among AMCs and regions dominated by large group practices.

The powers that be in health care are advocating more money to come directly from the taxpayer into the system to train more doctors, who will then cost the nation much more when they go into practice. Of course that’s a much easier answer for them than rational reorganization of the health care system by somehow or other making it all look more like Mayo.

So how do they start using language to persuade those of us suckers who are going to have to pony up for this that they’re right and the Dartmouth crew are wrong?

The AMA changed its position on the physician workforce a year ago, acknowledging that a shortage was indeed emerging. The consensus has shifted so quickly that experts who view the physician workforce as adequate — though poorly distributed, inefficient or wasteful — now are seen as contrarians.

So that’s it. Wennberg (and Goodman and Fischer and the rest of them) are now officially “contrarians”. Hmm…aren’t they the ones who make all the money on Wall Street?

CODA: The same edition of the LA Times has an article about the international outsourcing of radiology reading, which gives a clue as to how some of that “rational reorganization” might happen.


I was checking out potential book titles when I cam across this site, Health Care for Dummies. Given that I’ve spent some of the week beating up on the AMA, and spent some of yesterday touching on why the health care system looks like it does today—mostly based on Paul Starr’s book. But the real conspiracy theory is much more fun (even if I can’t exactly vouch for the truth). Read on for an amusing Friday diversion.

I’ll see ya back here on Tuesday



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